SDSU Health Insurance Enrollment Assistance 
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Email *
Please read these instruction before filling out this form!
Student's First and Last Name *
Parent / Guardian's first and last name (if this form is filled out on behalf of a student) *
Phone number *
Which SDSU campus are you enrolled? *
What class standing are you? *
Are you an international student (F1, J1)? *
Are you currently enrolled in Medi-Cal? *
If you are currently enrolled in Medi-Cal, please provide the name of the county where your Medi-Cal is active? *
Are you (the student) in need of serious or sudden medical treatment? *
Tax filling status *
Including yourself, how many people are in your taxable household? 

(This number includes the taxpayer(s) and any individuals who are claimed as dependents on one federal income tax return. A tax household may include a spouse and/or dependents).
*
On average, how much monthly income do you earn before taxes are taken?

 If you are not making any income please put 0.
 *
What, if any, other information that is important for us to know?
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