Emergency Contact Information and Insurance Waiver Selection

This emergency contact form must be filled out by every Crown College student. This information is for emergency purposes.

 

This form must be completed annually by each Crown College Student. *Student Athletes must complete and return this form by August 1st; All Students must complete and return this form by August 29th.

 

Fill out this form, then click the "Submit the Information..." button below...

Fields marked with * are required.

Your Information:

Are you a new student at Crown?: * Yes No

The information you are providing is effective beginning which semester/year:

Effective for Semester: * Fall Spring

Student Athlete: * Yes No

Insurance Information:


All Undergraduate students taking six or more credits are required to have health insurance. If the information below is not filled out completely, each student will be automatically billed $395 per semester and will be covered by the United Health insurance program provided by the College with coverage dates of August 15th (fall semester) through August 14th of the following year.

Insurance/Waiver Request: *

I REQUEST COVERAGE: I am not covered by a health insurance plan and will need the United Health Plan through Crown College.
I WAIVE COVERAGE: I am currently covered by a health plan and have provided the information below.

Does the policy cover athletic-related injuries: Yes No

Emergency Contacts:


Please provide contacts from two different households. (Your contacts do not necessarily need to be relatives.)

Primary Emergency Contact:


 

Secondary Emergency Contact:

*NOT in the same household as Primary Contact


 

Physician Information:

Additional Information:

Please provide the following if known.

Items marked with an * are required. When ready, click the button below to continue.