CLARK UNIVERSITY
STUDENT HEALTH INSURANCE PLAN

2015-16 POLICY YEAR
​SPRING WAIVER FORM

This form is for newly eligible students enrolled in the Spring 2016 semester.


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

Asterisk (*) denotes required field

STUDENT INFORMATION
 
first name: *
last name: *
social security number:
student ID: *
 

ID begins with the letter "C" followed by
the first eight digits of their Clark ID Card