EASTERN NAZARENE COLLEGE
STUDENT HEALTH INSURANCE PLAN

2018-19 POLICY YEAR

ADULT & GRADUATE STUDIES STUDENTS
ANNUAL TERM WAIVER FORM

ALL RETURNING AND NEW INCOMING STUDENTS FOR THE ANNUAL TERM MUST COMPLETE EITHER A WAIVER FORM OR ENROLLMENT FORM FOR FALL TERM 2018.
 
This form is for returning and new incoming students enrolled in the Fall, 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)