Student Medical Insurance Waiver/Enrollment

Personal Information

First Name: *

Last Name: *

Email Address: *

Insurance Information

Coverage: *

I will be enrolling in one of the student plans

I am currently insured by the carrier and policy listed below

I will be waiving coverage and assume responsibility for all medical expenses

Insurance company name: *

Policy number: *

By entering my initials below, I fully understand that I am legally responsible for any medical expenses incurred during my enrollment at the school and that the school will not be responsible for any medical expenses.

Initials: *

CAPTCHA

Our apologies for requiring that you complete this CAPTCHA verification step, but we find it necessary to eliminate spam submissions to our site. Thank you for your understanding. --Please click anywhere on the button below to proceed!