MASSACHUSETTS MARITIME ACADEMY
STUDENT HEALTH INSURANCE PLAN
2018-19 ACADEMIC YEAR

Annual 2018-19 Waiver Form
(August 1, 2018 - July 31, 2019)


TO CONTINUE THE WAIVER PROCESS, PLEASE FILL OUT THE REQUIRED FIELDS BELOW:

Asterisk (*) denotes required field

STUDENT INFORMATION

 
first name: *
last name: *
student ID: *
date of birth: * (MM/DD/YYYY)