Please fill out and submit the form below. The plan is available to all undergraduate and graduate, full- and part-time students. Spouses are also invited to become members when the student enrolls.
Registering Self: $299
Registering Self and Spouse: $598

Student Dental Health Plan Registration

Student's Last Name:
First Name:
MI:
Email Address:
Date of Birth:
Gender:
College in which you are enrolled:

Year of Graduation:
Student Identification Number:

Local Address
 
Street:
Apt#:
City:
State:
Zip:
Cell Phone:
- -

 Permanent Address is the same as Local Address

Permanent Address
 
Street:
Apt#:
City:
State:
Zip:
Are you a current SDP Member?
Yes No

If you are requesting a specific student dentist, plese provide the name here:
I am registering:
Myself Myself and my spouse