Consent Form (For Students Reserving the Rights NOT to Disclose Personal Information)

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This letter of Intent is to reserve the right of students not to disclose their personal information for Mahidol University to submit to the insurance company for the purpose of the COVID-19/Accident Insurance Scheme.

In accordance with the Data Privacy Policy, students who do not wish to enter into the COVID-19/Accident Insurance Scheme provided by Mahidol University and wish to reserve the right not to allow Mahidol University to submit personal information to the insurance company, have to fill out the form attached herewith.

The student hereby relinquishes the right to receive benefits and coverages from Mahidol University's COVID-19/Accident Insurance Scheme.

For Mahidol University to process the information, including the submission of the personal information to the insurance company, please select one of the following boxes: *

I do not wish to disclose my personal information

Firstname - Lastname: *

Student ID: *

Mobile Number: *

Please specify the reason to reserve the right not to allow Mahidol University to submit personal information to the insurance company:

Submit

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