Ascension Student Information Form

Email Secondary Email

There are errors with your form submission. Please review and submit again

Student Information

Personal Information

Student Name: *

Email address *

Address: *

Phone Number: *

City: *

State: *

Zip Code: *

Father's Name:

Mother's Name:

Street Address: *

City: *

State: *

Zip Code: *

Father's Phone Numbers (Home/Cell/Work)

Mother's Phone Numbers (Home/Cell/Work)

Father's Employer Name:

Mother's Employer Name:

Primary Physician Name:

Phone Number:

Address (Street, City, State & Zip Code):

Insurance Information

Insurance Company Name: *

Street Address: *

City: *

State: *

Zip Code: *

Phone Number: *

Policy Holder Name: *

ID Number: *

I certify that the foregoing information is true and correct.

Student Electronic Signature - Please type your First and Last Name: *

Date: *

Date Picker

Authorization to Release Information

I authorize any Health Care Provider, Insurance Company, Employer, Person or Organization to release information regarding medical, dental, mental, alcohol or drug abuse history, treatment or benefits payable, including disability or employment related information, to Summit America Insurance Services, Inc., d/b/a Ascension Benefits & Insurance Solutions, the Plan Administrator, or its employees and authorized agents for the purpose of validating and determining benefits payable. A photocopy of this authorization shall be as valid as the original.

Electronic Signature - Please type your First and Last Name: *

Date: *

Date Picker

* required field