EASTERN NAZARENE COLLEGE
STUDENT HEALTH INSURANCE PLAN

2019-20 POLICY YEAR

ADULT & GRADUATE STUDIES STUDENTS
ANNUAL TERM WAIVER FORM

ALL NEW INCOMING AND RETURNING STUDENTS FOR THE FALL TERM 2019 MUST COMPLETE EITHER A WAIVER FORM OR ENROLLMENT FORM.

 This form is for new incoming students and returning enrolled in the Fall, 2019 semester.


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

Asterisk (*) denotes required field

STUDENT INFORMATION

 
 (MM/DD/YYYY)