WAIVERS WILL ONLY BE VALID IF SUBMITTED ONLINE ON OR BEFORE THE WAIVER DEADLINE
For Annual or Fall: September 5, 2014 or for Spring February 6, 2015 or for Summer May 15, 2015.
Rockford University Health Insurance Waiver Form.
Students are required to have a health insurance policy in force while attending Rockford University.
I am waiving all rights to participate in the health insurance program that is offered through
Rockford University for the 2014-2015 academic year. I understand that by completing
this waiver I am stating that I am currently covered under the health insurance plan listed below.
If there is any change in coverage or expiration of coverage, I agree to notify the Lang Center
to update the insurance information I have on file.
During the 2014-2015 academic year I plan to participate in intercollegiate athletics:
BY CHECKING THE BOXES AND ENTERING MY NAME BELOW I AM INDICATING MY INTENT
TO ELECTRONICALLY SIGN THIS WAIVER AND WARRANT THAT ALL OF THE INFORMATION
I HAVE PROVIDED IS TRUE, COMPLETE, AND ACCURATE.
Student's Name Electronic Signature
Please type your name in the spaces below to electronically sign your waiver:
(Parent or guardian if under 18 years of age)
Please re-type your name in the spaces below to confirm your electronic signature:
You will automatically be enrolled in and billed for the insurance plan unless you are
covered by comparable insurance, and submit this form by the deadline date.
We recommend that you review your student account statement periodically to insure that
proper credit has been issued to your account. There will be absolutely no refunds for insurance after the enrollment period deadline. Any disputes on insurance waivers (waivers submitted after the
deadline) must be addressed with the Lang Center.
If you are experiencing any problems with this page please contact the webmaster.