DSU International Student Health Plan Card Pick Up Agreement

Once this form is completed, you will receive your plan card electronically. This may take up to 7 business days. Please save the e-mail and the attached card or print it for future use.

If you are under 18 years of age, you cannot complete this form yourself. You must go to the DSU Health Plan office and get a manual form to have your Parent/Guardian complete.

Exchange Students or those opting out with MSI should NOT complete this form but go to the DSU Health Plan office for assistance.

1Personal Information > 2Authorization > 3Final Release
Name * First Last
Student ID Number *
Email *

This is where your card will be sent
Date of Birth * / MM / DD YYYY
Gender *
Canadian Phone Number * - ### - ### ####
Address in Canada *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Home Country Phone Number *
Address in Home Country *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
If your Home Country is not listed, please enter CANADA in the drop down above, and enter your actual country in the box below