HEALTH INSURANCE CARD REGISTRATION INFORMATION

STUDENT INFORMATION

Student Full Name *

Class *

ID Number *

Date of Birth *

Gender *

Current Residence *

House Number, Street, Ward, District, City

Preferred Initial Medical Examination and Treatment Location

Please refer to the provided details at: https://pennschool.edu.vn/FcaEAH1k

Health Insurance Number *

Student's Health Insurance Card Number *

Full Name of the person registering health insurance for the student *

Relationship to the Student *

Other relationship *

Phone Number *

of Card Certificate

ID Number *

Image of the ID Card (both sides) *

Click or drag files to this area to upload. You can upload up to 4 files.

Image of the Student's Birth Certificate *

Click or drag files to this area to upload. You can upload up to 4 files.

Registration Form