Gordon-Conwell Theological Seminary
STUDENT HEALTH PLAN

Spring 2016 Waiver Form

Newly eligible Spring 2016 students taking 6+ credits at South Hamilton (or 9+ credits at Boston) who will have adequate health insurance from January 15, 2016, through August 31, 2016, can submit this waiver form to opt out of the Student Health Plan.

If you do not complete this waiver form by midnight on February 5, 2016, you will be charged for the Student Health Plan on your student account.

If you do not complete this waiver form by the FINAL DEADLINE of midnight on February 19, 2016, you will be unable to remove the charge on your student account.


This form is for Spring 2016 who were not eligible
for the Student Health Plan during Fall 2015.


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)