Salve Regina University
STUDENT HEALTH INSURANCE PLAN

SPRING WAIVER FORM
1/15/2019 - 8/15/2019


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)