EASTERN NAZARENE COLLEGE
STUDENT HEALTH INSURANCE PLAN

2018-19 POLICY YEAR

ADULT & GRADUATE STUDIES STUDENTS
SPRING TERM WAIVER FORM

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

 This form is for new incoming students enrolled in the Spring, 2019 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)