Enrolling in the St Charles Community College Insurance Plan

Please complete the information below for your health insurance enrollment. You'll want to make sure to sign up for the full period of your program.

Fields with * are required.

Enrollment Code Please contact your sponsoring organization for this information.

First Name

Middle Name

Last Name

**Please be sure to enter your name exactly as it appears on your passport.

Date of Birth

Gender

Gender X

Yes No

Telephone

Visa Type

Start Date The date you begin travel for your program.

End Date The last day of travel for your program.

Are you a US citizen?

Yes No

What is the name of your home country?

Are you traveling to the US?

Yes No

Please note, if you enter any address information, you must complete all of the address information.

Address Line 1

Address Line 2

City

Postal Code

Country Name

State Name

Billing Address is the same as Mailing Address

Self-enrollment for St Charles Community College