MASSACHUSETTS MARITIME ACADEMY
STUDENT HEALTH INSURANCE PLAN
2017-18 ACADEMIC YEAR

Spring 2018 Waiver Form
(January 1, 2018 - July 31, 2018)


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)