SUFFOLK UNIVERSITY

STUDENT HEALTH INSURANCE PROGRAM 
2015-2016 ACADEMIC YEAR
WAIVER FORM

 

The deadline for submitting the Fall waiver form is September 30, 2015.

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)