EASTERN NAZARENE COLLEGE
STUDENT HEALTH INSURANCE PLAN

2017-18 POLICY YEAR

ADULT & GRADUATE STUDIES STUDENTS
SPRING TERM WAIVER FORM

ALL NEW INCOMING STUDENTS FOR SPRING TERM MUST COMPLETE EITHER A WAIVER FORM OR ENROLLMENT FORM FOR THE SPRING 2018 TERM.

This form is for new incoming students enrolled in the Spring 2018 semester.


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)