International Student Health Insurance

International Student Health Insurance

Lang Wellness Center 815-226-4083 healthcenter@rockford.edu
Please make sure you complete this form before you arrive at Rockford University.
Name*

First NameMiddle NameLast Name
Phone Number
Please enter a valid phone number.
Birth Date*

MonthDayYear
Rockford University Email*
example@example.com
Are you a Rockford University Student Athlete?*

YesNo
Do you have adequate health insurance (including intercollegiate sports participation) to cover you during the 2025 - 2026 academic year?*

YesNo
Do you have adequate health insurance to cover you during the 2025 - 2026 academic year? Adequate health insurance plans include those provided by GoCampus and SACM.*

YesNo
Please upload a copy of your health insurance card.*

Cancelof
I understand that by signing below, I am stating that I am currently covered by a health insurance plan (copy of the front and back of the card uploaded above) and the plan has adequate coverage (including intercollegiate sports participation). If there is any change in coverage or expiration of coverage during the 2025- 2026 academic year, I agree to notify Lang Wellness Center immediately to update my health insurance.*

Clear
I understand that by signing below, I am stating that I am currently covered by a health insurance plan (copy of the front and back of the card uploaded above) and the plan has adequate coverage for the 2025 - 2026 academic year. Adequate health insurance plans include those provided by GoCampus and SACM. If there is any change in coverage or expiration of coverage during the 2025 - 2026 academic year, I agree to notify Lang Wellness Center immediately to update my health insurance.*

Clear
Please complete the information below to enroll in CareMed - our international student health insurance - Platinum Plan. Your Rockford University student account will be billed for this health insurance coverage. The cost of this international health insurance is $157.48 per month.

Please contact Lang Wellness at 815-226-4083 or healthcenter@rockford.edu with any questions.
Gender*
Home Country*
Destination City*
Insurance Start Date*
month/day/year
Insurance End Date*
month/day/year
By typing my name below, I understand and agree that this form of electronic signature has the same legal force and effect as a manual signature.*
Type Full Name
Date*

MonthDayYear
Please contact Lang Wellness Center/Rockford University at 815-226-4083 Monday - Friday to enroll in our international athletic health insurance.
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