Student Insurance Information

Student Information

First Name*

Last Name*

Birthdate*

Non-KWC Email*

Student Status*

I am a continuing student

I am a new, transfer, or readmitted student

Insurance Coverage Information

Do you have health insurance coverage?*

Yes

Student insurance coverage information is required to be on file in the Office of Student Health Services. Do you have your insurance coverage information available to submit with this form?*

Yes

Front of Insurance Card

Back of Insurance Card

Acknowledgement

I have reviewed information listed on this form or I acknowledge that there are no changes to my personal information. I understand that by completing this health form, information may be shared with Kentucky Wesleyan College's physicians, nurses, and mental health counselors. Furthermore, I acknowledge that all information supplied on this form is current and correct to the best of my knowledge.

Yes

Student Name

Click to Sign...

Signature Date