Gordon-Conwell Theological Seminary
STUDENT HEALTH PLAN

Annual 2015-2016 Waiver Form

New and newly eligible spring students taking 6+ credits at South Hamilton (or 9+ credits at Boston) who will have adequate health insurance from September 1, 2015, 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 September 25, 2015, 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 October 9, 2015, you will be unable to remove the charge on your student account.


This form is for Fall 2015 students. 


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

Asterisk (*) denotes required field

STUDENT INFORMATION
 
student ID: *
first name: *
last name: *
date of birth: * (MM/DD/YYYY)