HEALTH INSURANCE CARD REGISTRATION INFORMATION

STUDENT INFORMATION

Student Full Name *Student Full Name *

Class *Class *

of Card and

ID Number *ID Number *

Date of Birth *Date of Birth *

Gender *Gender *

Current Residence *Current Residence *

House Number, Street, Ward, District, City

Preferred Initial Medical Examination and Treatment LocationPreferred Initial Medical Examination and Treatment Location

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

Health Insurance Number *Health Insurance Number *

Student's Health Insurance Card Number *Student's Health Insurance Card Number *

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

Relationship to the Student *Relationship to the Student *

Other relationship *Other relationship *

Phone Number *Phone Number *

ID Number *ID Number *

Image of the ID Card (both sides) *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 *Image of the Student's Birth Certificate *

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

Hộp kiểm *Hộp kiểm *

I confirm that the personal information provided is accurate and consent to the School collecting, storing, processing, and using it in accordance with personal data protection laws for the purpose of admission consultation.

Registration Form