International Student

First Name:*

Middle Name:

Last Name:*

G#:*

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 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Gender:*
Male Female

Address:*

City:*

State:*
- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming

Zip Code:*

Country Of Citizenship:*

Email Address:*

Cell Phone: (xxx-xxx-xxxx)

Section A

I elect not to purchase the Insurance Plan offered by Grand Valley State University. By checking this box and signing below, I am certifying that I have purchased a policy that meets the minimum standards required by the university: $50,000 or more in medical benefits, $7,500 for repatriation of mortal remains, $10,000 for medical evacuation to my home country, and $500 or smaller deductible amount. I also certify that I will maintain this coverage at all times while I am a student at Grand Valley State University.

I wish to purchase the insurance plan offered by Grand Valley State University. My Insurance Premium will be charged to my Student Account. Cost for the 2012-2013 academic year is $534.00 per six months ($1068.00 per calendar year).

I understand that international students are required to have health insurance for the duration of the academic program.