LASELL COLLEGE
STUDENT HEALTH INSURANCE PLAN

Spring Waiver Form
2016-2017 Academic Year

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

Please note that your student ID must contain 9 digits (example: 000012345)

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