Modified Course Load Opt-In Online Application
This online application is to be completed by those who are registered full-time with modified course load and/or are registered with the Accessible Learning Services Department. Please ensure that you input the correct information below, as well as, provide a copy of a letter from the Registrar Department or Accessible Learning Services Department confirming that you are a full-time student with modified course load and/or registered with the Accessible Learning Services Department.
Student ID Number *
Your answer
Program Name *
Your answer
Campus Study *
Required
Program Start Date *
MM
/
DD
/
YYYY
First Name *
Your answer
Last Name *
Your answer
Gender *
Required
Date of Birth *
MM
/
DD
/
YYYY
Phone Number *
Your answer
E-mail address *
Your answer
Complete address including postal code *
Your answer
Please describe the circumstances that led you (the applicant) to opt-in for Health and Dental Coverage: *
Your answer
Date of loss of coverage
MM
/
DD
/
YYYY
Date of commencement of restored coverage
MM
/
DD
/
YYYY
The plan I am choosing is (choose one of the following): *
There are 4 different plans you can choose from at no additional cost. To review the plan overview, you can visit https://wespeakstudent.com/home/47-george-brown-college/domestic-plan
I understand that: *
Required
Method of Payment
Please note that we only accept the following method of payment, which you can complete at the Student Association office, as soon as, we contact you to complete your payment:

• Credit (Visa/Mastercard)
• Debit

Submit
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