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

Waiver Form


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)