* denotes a required field
Preferred Campus Location * - Select Option Allendale Grand Rapids Muskegon
Dates and Allendale Locations * - Select Option September 28- KC2215/2216 October 3- Fieldhouse October 13- KC 2215/2216 October 28- Fieldhouse
September 28th Kirkhof Center Room 2215/2216 11:00 a.m.-1:00 p.m. * - Select Option 11:00 a.m. (0 available) 11:10 a.m. (0 available) 11:20 a.m. (0 available) 11:30 a.m. (0 available) 11:40 a.m. (13 available) 11:50 a.m. (14 available) 12:00 p.m. (3 available) 12:10 p.m. (8 available) 12:20 p.m. (13 available) 12:30 p.m. (9 available) 12:40 p.m. (15 available) 12:50 p.m. (5 available)
October 3rd Field house Hall of Fame Room 11:00 a.m.-1:00 p.m. * - Select Option 11:00 a.m. (0 available) 11:10 a.m. (4 available) 11:20 a.m. (15 available) 11:30 a.m. (6 available) 11:40 a.m. (10 available) 11:50 a.m. (13 available) 12:00 p.m. (10 available) 12:10 p.m. (16 available) 12:20 p.m. (16 available) 12:30 p.m. (10 available) 12:40 p.m. (11 available) 12:50 p.m. (9 available)
October 13th Kirkhof Center Room 2215/2216 12:00 p.m.-2:00 p.m. * - Select Option 12:00 p.m. (0 available) 12:10 p.m. (0 available) 12:20 p.m. (0 available) 12:30 p.m. (0 available) 12:40 p.m. (0 available) 12:50 p.m. (1 available) 1:00 p.m. (2 available) 1:10 p.m. (7 available) 1:20 p.m. (10 available) 1:30 p.m. (2 available) 1:40 p.m. (13 available) 1:50 p.m. (6 available)
October 28th Fieldhouse Hall of Fame Room 11:00 a.m.-1:00 p.m. * - Select Option 11:00 a.m. (0 available) 11:10 a.m. (0 available) 11:20 a.m. (13 available) 11:30 a.m. (3 available) 11:40 a.m. (13 available) 11:50 a.m. (16 available) 12:00 p.m. (3 available) 12:10 p.m. (12 available) 12:20 p.m. (13 available) 12:30 p.m. (6 available) 12:40 p.m. (14 available) 12:50 p.m. (10 available)
Dates and Grand Rapids Location * - Select Option September 29th- Family Health Center October 4th- University Club October 6th- Family Health Center October 12th- DCIH Room 102 October 17th- University Club October 20th- DCIH Room 445
September 29th- Family Health Center 5:00 p.m.-7:00 p.m. * - Select Option 5:00 p.m. (3 available) 5:10 p.m. (16 available) 5:20 p.m. (15 available) 5:30 p.m. (14 available) 5:40 p.m. (15 available) 5:50 p.m. (16 available) 6:00 p.m. (7 available) 6:10 p.m. (16 available) 6:20 p.m. (16 available) 6:30 p.m. (10 available) 6:40 p.m. (15 available) 6:50 p.m. (15 available)
October 4th University Club Pew Campus 12:00 p.m.-2:00 p.m. * - Select Option 12:00 p.m. (0 available) 12:10 p.m. (0 available) 12:20 p.m. (0 available) 12:30 p.m. (5 available) 12:40 p.m. (14 available) 12:50 p.m. (12 available) 1:00 p.m. (4 available) 1:10 p.m. (13 available) 1:20 p.m. (14 available) 1:30 p.m. (11 available) 1:40 p.m. (14 available) 1:50 p.m. (10 available)
October 6th- Family Health Center 7:00 a.m.-9:00 a.m. * - Select Option 7:00 a.m. (16 available) 7:10 a.m. (16 available) 7:20 a.m. (15 available) 7:30 a.m. (16 available) 7:40 a.m. (16 available) 7:50 a.m. (16 available) 8:00 a.m. (12 available) 8:10 a.m. (16 available) 8:20 a.m. (16 available) 8:30 a.m. (16 available) 8:40 a.m. (16 available) 8:50 a.m. (14 available)
October 12th DCIH Room102 11:00 a.m.-1:00 p.m. * - Select Option 11:00 a.m. (0 available) 11:10 a.m. (8 available) 11:20 a.m. (12 available) 11:30 a.m. (11 available) 11:40 a.m. (16 available) 11:50 a.m. (14 available) 12:00 p.m. (12 available) 12:10 p.m. (15 available) 12:20 p.m. (14 available) 12:30 p.m. (8 available) 12:40 p.m. (14 available) 12:50 p.m. (10 available)
October 17th University Club Pew Campus 11:00 a.m.-1:00 p.m. * - Select Option 11:00 a.m. (0 available) 11:10 a.m. (0 available) 11:20 a.m. (5 available) 11:30 a.m. (7 available) 11:40 a.m. (14 available) 11:50 a.m. (14 available) 12:00 p.m. (10 available) 12:10 p.m. (16 available) 12:20 p.m. (15 available) 12:30 p.m. (9 available) 12:40 p.m. (15 available) 12:50 p.m. (11 available)
October 20th DCIH Room 445 1:00 p.m.-3:00 p.m. * - Select Option 1:00 p.m. (1 available) 1:10 p.m. (12 available) 1:20 p.m. (16 available) 1:30 p.m. (12 available) 1:40 p.m. (15 available) 1:50 p.m. (15 available) 2:00 p.m. (14 available) 2:10 p.m. (13 available) 2:20 p.m. (14 available) 2:30 p.m. (15 available) 2:40 p.m. (15 available) 2:50 p.m. (13 available)
Dates and Muskegon Location * - Select Option October 14th- Annis Water Resources Institute
October 14th- Annis Water Resources Institute 9:00 a.m.-10:00 a.m. * - Select Option 9:00 a.m. (0 available) 9:10 a.m. (0 available) 9:20 a.m. (2 available) 9:30 a.m. (4 available) 9:40 a.m. (5 available) 9:50 a.m. (5 available) 10:00 a.m. (7 available)
First Name *
Last Name *
(maiden/previous name)
G-number *
Date of Birth * - Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 - 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900
Age *
GVSU Status * - Select Option GVSU Faculty/Staff (Benefit Eligible) GVSU Faculty/Staff (Not Benefit Eligible) Spouse (Benefit Eligible Employee) Dependent of GVSU Faculty/Staff (Benefit Eligible Employee) Retiree GVSU Student Other
Varsity Student Athlete * - Select Option Yes No
Insurance Type * - Select Option Aetna ASR Blue Care Network (HMO) Blue Cross Blue Shield (PPO) Blue Cross Complete McLaren Medicaid Medicare Meridan Molina Priority Health Tricare United Healthcare Other Insurance No Insurance (self-pay)
Please specify "Other Insurance" *
Policy Holder Name *
Member ID/ Enrollment Number *
Group Number *
Email *
Phone *
Country * - Select Country Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentine Republic Armenia Aruba Australia Austria Azerbaijan Azores Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos Colombia Comoros Congo Cook Islands Costa Rica Cote D'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Do Not Use Do Not Use Do Not Use Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Islands Finland France French Polynesia Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Republic of Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Island Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda S Georgia Sandwich Islands Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent The Grenadines San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovak Republic Slovenia Solomon Islands Somalia South Africa South Korea Spain Sri Lanka Sudan Suriname Svalbard Swaziland Sweden Switzerland Syria Taiwan, Rc Tajikistan Tanzania Thailand The Bahamas The Congo Togolese Republic Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States of America Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands (British) Virgin Islands (US) Wallis and Futuna Western Sahara Western Samoa Yemen Zambia Zimbabwe
Address 1 *
Address 2
City *
State/Province * - Select State Alabama Alaska American Samoa Arizona Arkansas Armed Forces Afr/Can/EU/ME Armed Forces Americas Armed Forces Pacific Baker Island California Colorado Connecticut Delaware Federated State of Micronesia Florida Georgia Guam Hawaii Howland Island Idaho Illinois Indiana Iowa Johnston Atoll Kansas Kentucky Kingman Reef Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Midway Islands Minnesota Mississippi Missouri Montana Navassa Island Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Palmyra Atoll Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Trust Territory of Pacific Utah Vermont Virgin Islands Virginia Wake Island Washington Washington D.C. West Virginia Wisconsin Wyoming - Select Province Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon
Zip/Postal *
Human Verification *