WORCESTER STATE UNIVERSITY

STUDENT HEALTH INSURANCE PROGRAM WAIVER FORM
2017-2018 ACADEMIC YEAR
SPRING SEMESTER


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

PLEASE NOTE: YOUR WORCESTER STUDENT ID# CONSISTS OF 7 digits FOLLOWING 0XXXXXX. IF YOU DO NOT KNOW YOUR ID#, PLEASE CONTACT LAURIE RIESER AT THE BURSAR'S OFFICE AT 508-929-8816.

Asterisk (*) denotes required field

STUDENT INFORMATION
 
first name: *
last name: *
student ID: * (7 digits including leading zeros)
date of birth: * (MM/DD/YYYY)