NSCAD 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. Processing will take 5-10 business days.

If you are under 18 years of age, you cannot complete this form yourself. You must go to the NSCAD 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 NSCAD 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 (if you do not have a Canadian phone number, please enter all 0's). * - ### - ### ####
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 home country not displayed, please enter Canada in the drop down menu & your actual home country here