Returning Student Registraion Forms

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Insurance Declaration Form

Student's First Name: *

Student's Last Name: *

Do you plan to live ON campus? *

I have health insurance and understand that I must keep it current while I am a student living on campus. I understand that I must provide a copy of my insurance card or other documentation of current health insurance coverage to the Student Life Office by the first day of classes or I will be blocked from attending class (counted as an unexcused absence). Please enter your initials below indicating you understand. * Please enter initials.

If you are interested in the health insurance plan offered through the college, please contact American College Student Association, www.ACSA.com, toll free telephone number: 888-526-2272, for information on their Student Injury and Sickness Insurance Plan designed especially for domestic participants of ACSA. The ACSA membership fee of $18.00 is waived for students who enroll online at www.ACSA.com/JoinNow. This is informational only. You do not need to enter anything in this box.

Do you have your own insurance or have you purchased the health insurance plan offered through the college?

Insurance Company: * Enter your insurance company name.

Insurance Policy Number: *

Will you carry health insurance?

Insurance Company: * Enter your insurance company name.

Insurance Policy Number: *

By typing my name below I am stating that I fully understand that I am legally responsible for any medical expenses incurred during my enrollment at Florida Christian College and that the school will not be responsible for any medical expense.

Student's Typed Signature: *

Date: *

Parent’s Typed Signature (If Student Minor):

Date:

Request For Campus Parking

Student's First Name *

Student's Last Name *

Are you a commuter or resident student? *
Commuter
Resident

Year of Vehicle: * Enter NA if you will not need a parking permit.

Make & Model of Vehicle * Enter NA if you will not need a parking permit.

Color of Vehicle: * Enter NA if you will not need a parking permit.

State Vehicle Licensed In: * Enter NA if you will not need a parking permit.

License Plate Number: * Enter NA if you will not need a parking permit.

The Following Will Be Completed When You Come To Registration

Information Verification Signature

My signature below indicates that I have carefully read and reviewed these completed forms. I verify and confirm that the information and responses are both accurate and represent my wishes. I also verify and affirm that my initials on each page of this document indicate that I have read and reviewed each page and that I understand the information on each page.

Student's Printed Name: _____________________________________

Student's Signed Name: ______________________________________

Parent Verification if the student is a minor

Printed Name: ______________________________________________

Signed Name: _______________________________________________

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