Enrollment Form (School Year 2021-2022) Step 1 of 2 50% For Your Records, please Download and print a copy of the Plan Brochure Before Proceeding to Online Application Last Name (Family Name)* First Name* Middle Name Birth Date (MO/DY/YR)* MM slash DD slash YYYY Phone*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email School System/District* School Name* Parent or Guardian* Date* MM slash DD slash YYYY Student Insurance Plan Options - Choose Your Selection(s)24-Hour Basic ($85.00) Preferred ($135.00) Premier ($225.00) 24-Hour Summer Only Basic ($29.00) Preferred ($44.00) Premier ($69.00) School Time Basic ($19.50) Preferred ($32.00) Premier ($49.00) Football (Including Spring) Basic ($98.50) Preferred ($168.50) Premier ($278.00) Football (Seniors - No Spring) Basic ($79.50) Preferred ($139.50) Premier ($229.00) Spring Football (New Players) Basic ($19.00) Preferred ($29.00) Premier ($49.00) Full Time Dental Basic ($7.00) 24 Hour - Basic Price: 24 Hour - Preferred Price: 24 Hour - Premier Price: 24-Hour Summer Only - Basic Price: 24 Hour Summer Only - Preferred Price: 24 Hour Summer Only - Premier Price: School Time - Basic Price: School Time - Preferred Price: School Time - Premier Price: Football (Including Spring) - Basic Price: Football (Including Spring) - Preferred Price: Football (Including Spring) - Premier Price: Football (Seniors - No Spring) - Basic Price: Football (Seniors - No Spring) - Preferred Price: Football (Seniors - No Spring) - Premier Price: Spring Football (New Players) - Basic Price: Spring Football (New Players) - Preferred Price: Spring Football (New Players) - Basic Price: Full Time Dental Price: Total $0.00 Credit Card* American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Month010203040506070809101112 Year20222023202420252026202720282029203020312032203320342035203620372038203920402041 Expiration Date Security Code Cardholder Name Δ En español
