Please Complete the Registration and Payment Sections Below

Membership Registration
Create Your Login Credentials
*
Email Address
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Please enter valid email address.
Please enter valid email address.
This email is already registered, please choose another one.
*
Confirm Email Address
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Please enter email address again.
Please enter email address again.
Please enter email address again.
*
Password
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Please enter valid data.
Please enter at least 6 characters.
    Strength: Very Weak
    *
    Confirm Password
    Confirm Password can not be left blank.
    Passwords don't match.
    Passwords don't match.
    Parent Demographics
    *
    Parent 1 First Name
    First Name can not be left blank.
    Please enter valid data.
    Please enter valid data.
    This first name is invalid. Please enter a valid first name.
    *
    Parent 1 Last Name
    Last Name can not be left blank.
    Please enter valid data.
    Please enter valid data.
    This last name is invalid. Please enter a valid last name.
    *
    Parent 1 Address
    Text field can not be left blank.
    Please enter valid data.
    Street, City, State, and ZIP
    *
    Parent 1 Preferred Phone #
    Text field can not be left blank.
    Please enter valid data.
    Parent 2 First Name
    Text field can not be left blank.
    Please enter valid data.
    Parent 2 Last Name
    Text field can not be left blank.
    Please enter valid data.
    *
    Is the address for both parent's the same?
    YesNo
    Please select one option.
    Please enter valid data.
    Parent 2 Address
    Text field can not be left blank.
    Please enter valid data.
    If different from Parent 1
    Parent 2 Preferred Phone #
    Text field can not be left blank.
    Please enter valid data.
    Parent 2 Preferred Email Address
    Text field can not be left blank.
    Please enter valid data.
    Student's Information
    *
    Student's Full Name
    Text field can not be left blank.
    Please enter valid data.
    *
    Student's Date of Birth
    Please select date.
    Invalid Date.
    *
    Legal Sex
    MaleFemale
    Please select one.
    Please enter valid data.
    *
    Student's Local Physical Address
    Text field can not be left blank.
    Please enter valid data.
    Street, City, State, ZIP
    *
    Student's Cell Phone #
    Text field can not be left blank.
    Please enter valid data.
    Including Area Code
    *
    Student's Primary Email Address
    Text field can not be left blank.
    Please enter valid data.
    Insurance Policy Information
    *
    Insurance Company Name
    Text field can not be left blank.
    Please enter valid data.
    ie: BCBS, Aetna, United...
    *
    Insurance ID #
    Text field can not be left blank.
    Please enter valid data.
    Enrollee ID, including Alpha-prefix if applicable
    Insurance Card
    Please select file.
    Invalid file selected.
    Invalid file selected.
    Front of Card
    Insurance Card
    Please select file.
    Invalid file selected.
    Invalid file selected.
    Back of Card
    Select Your Payment Gateway
    Bank Name
    Please enter Bank Name.
    Account Holder Name
    Please enter Account Holder Name.
    Card Holder Name
    Credit Card Number
    Card Number should not be blank.
    Please enter at least 13 digits.
    Maximum 16 digits allowed.
    Please enter correct card details.
    Expiration Month
    Expiry month should not be blank.
    Expiration Year
    Expiry year should not be blank.
    CVV Code
    CVC Number should not be blank.
    How you want to pay?
    Have a coupon?
    Apply
    Payment Summary

    Your currently selected plan :
    Plan Amount :

    Final Payable Amount:
    Submit

    By clicking "Submit," you are agreeing to StudentHealthConnect's Terms of Service.

    Once your payment is processed, we will begin processing your registration.
    Once these processes are complete, keep an eye out for a "Welcome" email from us, which will contain information and instructions you will need to take full advantage of StudentHealthConnect's services.