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 NameBirth Date (MO/DY/YR)* Date Format: 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* Date Format: 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: $85.00 24 Hour - Preferred Price: $135.00 24 Hour - Premier Price: $225.00 24-Hour Summer Only - Basic Price: $29.00 24 Hour Summer Only - Preferred Price: $44.00 24 Hour Summer Only - Premier Price: $69.00 School Time - Basic Price: $19.50 School Time - Preferred Price: $32.00 School Time - Premier Price: $49.00 Football (Including Spring) - Basic Price: $98.50 Football (Including Spring) - Preferred Price: $168.50 Football (Including Spring) - Premier Price: $278.00 Football (Seniors - No Spring) - Basic Price: $79.50 Football (Seniors - No Spring) - Preferred Price: $139.50 Football (Seniors - No Spring) - Premier Price: $229.00 Spring Football (New Players) - Basic Price: $19.00 Spring Football (New Players) - Preferred Price: $29.00 Spring Football (New Players) - Basic Price: $49.00 Full Time Dental Price: $7.00 Total $0.00 Credit Card* American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20212022202320242025202620272028202920302031203220332034203520362037203820392040 Expiration Date Security Code Cardholder Name En español
