Emerson College
STUDENT HEALTH INSURANCE PLAN

Undergraduate Student Waiver Form
2019-2020 Academic Year

The waiver deadline is September 17, 2019

If the student is a minor, then the parent or guardian must complete this form.

You must enter the correct Emerson Student ID to access the form. The Emerson Student ID begins with E and is followed by 8 digits.

Asterisk (*) denotes required field

STUDENT INFORMATION

 
 (MM/DD/YYYY)