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SDSU Health Insurance Enrollment Assistance
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Email
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Your email
Please read these instruction before filling out this form!
Student's First and Last Name
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Your answer
Parent / Guardian's first and last name (if this form is filled out on behalf of a student)
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Your answer
Phone number
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Your answer
Which SDSU campus are you enrolled?
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Imperial Valley
San Diego Campus (campus on the mesa)
What class standing are you?
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Graduate student
Undergraduate
Open-University / Global Campus
Are you an international student (F1, J1)?
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Yes
No
Are you currently enrolled in Medi-Cal?
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Yes
No
If you are currently enrolled in Medi-Cal, please provide the name of the county where your Medi-Cal is active?
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Your answer
Are you (the student) in need of serious or sudden medical treatment?
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Yes
No
Maybe
Tax filling status
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Primary tax filer
Dependent (under parent / legal guardian)
I don't make enough to file
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).
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1 (myself)
2 people
3 people
4 people
5 people
Other:
On average, how much monthly income do you earn before taxes are taken?
If you are not making any income please put 0.
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Your answer
What, if any, other information that is important for us to know?
Your answer
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