Salve Regina University
STUDENT HEALTH INSURANCE PLAN

ANNUAL WAIVER FORM
8/15/2018 - 8/15/2019


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

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STUDENT INFORMATION

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