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Franklin Cummings Tech
STUDENT HEALTH INSURANCE PLAN

Annual Enrollment Form
2024-2025 Academic Year

 

TO CONTINUE THE ENROLLMENT PROCESS, PLEASE FILL OUT THE REQUIRED FIELDS BELOW:

Please note, your student ID# begins with an "A" followed by 10 digits

Asterisk (*) denotes required field

STUDENT INFORMATION

 (MM/DD/YYYY)