Mathcamp@AU
Summer2016
StudentHealthInsuranceForm
All Mathcamp@AU students must have health insurance while attending the camp.
Please follow these instructions to provide evidence of your current health insurance.
1. Make a copy of your insurance card.
2. Fill out this form.
3. Return this form to Mathcamp@AU, making sure to include a copy of your insurance card.
______________________________________________________________________________
I declare that I have medical insurance coverage for accident and sickness in force in the
U.S. that will cover me during my enrollment in Mathcamp@AU.
(Print) Student’s Name
(Print) Name of Insured
Relationship to Student
Name of Insurance Company
Policy Number
I acknowledge that health insurance is required to attend Mathcamp@AU at American
University.
Signature of Student
Date
_________________________________________
Signature of Parent or Guardian
______________________________
Parent/Guardian Printed Name