DCSA Home Country Opt-Out Form

BY SIGNING THIS DOCUMENT YOU WILL WAIVE CERTAIN LEGAL RIGHTS, INCLUDING THE RIGHT TO SUE. PLEASE READ CAREFULLY

International students registered and enrolled in the Spring 2022 semester at Durham College who are not physically present in Canada may request a refund of the fees paid for Morcare Health insurance (offered by Durham College Student Association) AND StudentVIP Extended Benefits insurance coverage (offered by Durham College Student Association). This option is only available to those not physically present in Canada.

Please Note: You will be required to opt-out each term you are outside of Canada.

First Name *
Last Name *
Date of Birth * / MM / DD YYYY
I am over the age of 18 *
True False
Student ID Number *
Must be 9 digits. Currently Entered: 0 digits.
School Issued Email *
I understand and acknowledge that by signing this Waiver, I waive any entitlement to Morcare Health Insurance and StudentVIP Extended Benefits insurance coverage while I continue to be registered in the Spring 2022 semester at Durham College. *
Yes, I Agree
I acknowledge and understand that, having opted out of Morcare Health Insurance and Student VIP Extended Benefits insurance coverage, if I have an injury, accident or become ill, I will be personally and solely responsible for all of my medical costs. *
Yes, I Agree
I acknowledge and understand that I do not have life insurance provided by Morcare. *
Yes, I Agree
I acknowledge and understand that I do not have travel insurance provided by Morcare or Student VIP Extended Benefits insurance coverage. *
Yes, I Agree
I also understand that by accepting the health insurance benefit refund, I will NOT:

• Have health insurance coverage provided by Morcare OR StudentVIP from Sept 1, 2021 to midnight on Aug 31st, 2022 - in Canada or any other country
*
Yes, I Agree
I understand that should I plan to travel to Canada, I am required to inform Durham College of my intended arrival date should this occur before August 31, 2022 *
Yes, I Agree
In consideration of Durham College and Durham College Students Inc. permitting me to opt out of the Extended Benefits insurance coverage and obtaining a refund of fees paid for such coverage, I hereby agree to waive any and all claims that I have or may have in the future against Durham College and Durham College Student Inc.,, their directors, officers, employees, agents and volunteers (all of whom will be hereafter referred to as “Releasees”), arising directly or indirectly from my voluntary opt out and refunding of the health insurance plan fees. Further, I agree to release, discharge and indemnify the Releasees from any and all liability for any loss, damage, injury or expense that I, my next of kin or any third party may suffer as a result of my opting out of the health insurance plans, including any wrongful act, omission, negligence, breach of contract, breach of any statutory or other duty of care, on the part of the Releasees.

I hereby agree to the disclosure of personal information held by Durham College and Durham College Students Inc., in accordance with the Freedom of Information and Protection of Privacy Act, 2002, RSO 1990, c F.31,to my next of kin or my legal representative, or a Canadian official, in the event of my death, incapacity or compelling circumstances affecting my health and safety.

I am aware that this Agreement shall be effective and binding upon my heirs, next of kin, executors, administrators and assigns in the event of my death or incapacity and that the terms of this document shall apply and have priority over any previous agreement or written agreement, representation, term or condition on the contrary. This Agreement shall be governed by and interpreted in accordance with the laws of the Province of Ontario. Any litigation involving the parties to this Agreement shall be brought within the Province of Ontario.

I HAVE READ AND UNDERSTOOD THIS RELEASE PRIOR TO SIGNING IT AND I ACKNOWLEDGE THAT I HAVE HAD THE OPPORTUNITY TO SEEK LEGAL ADVICE REGARDING THIS RELEASE. IN ADDITION, I AM AWARE THAT BY SIGNING THIS RELEASE I AM WAIVING CERTAIN LEGAL RIGHTS WHICH I OR MY HEIRS, NEXT OF KIN, EXECUTORS, ADMINISTRATORS AND ASSIGNS MAY HAVE AGAINST THE RELEASEES.
*
Yes, I Agree
Upload Proof of Residency - Passport or Other Documentation *

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If you are under the age of 18, please have a parent or guardian sign here.

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