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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