WASHINGTON COLLEGE

STUDENT ACCIDENT & SICKNESS INSURANCE PROGRAM
FOR THE 2014-2015 ACADEMIC YEAR

WAIVER FORM FOR FALL 2014 STUDENTS


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

The deadline for submitting the waiver form is July 15, 2014.

Asterisk (*) denotes required field

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