Employee Information

Name (Last, First, Middle):

Employee ID#: (printed on paycheck stub)

Home address
Number, Street, & Apt.:

City: State: Zip:

Home phone: Campus phone: Email:

Recipient (check one):
Employee     Spouse (Marriage date: )     Registered Domestic Partner
Dependent Child*     Dependent Child of a domestic partner*

* Documentation to verify the relationship of a spouse, domestic partner, or dependent child (marriage certificate, birth certificate, domestic partner affidavit) is required with this enrollment form unless you have verified the relationship previously for IU-sponsored medical or dental plan enrollment.

Student Information

Name: Same as above
(Last, First, Middle)

Birth Date:    Gender: Male    Female

Citizenship:

Dragon User ID#: (assigned to you if you have previously registered for Indiana University High School courses)

Home address: Same as above
Number, Street, & Apt.:

City: State: Zip:

Complete the following for Dependent Child Tuition Waiver:

• Is the child married?     Yes   No

• Does the child meet the IRS requirements to be claimed as a
  Federal Income Tax Dependent?    Yes   No

• Is the child age 23 or under?*     Yes   No

• Is the child totally disabled?     Yes   No

* Dependents are eligible through age 23, as long as the child can be claimed as an income tax dependent of the employee.  Regardless of tax-exempt status, eligibility ceases at the end of the month in which the child reaches age 24, unless the child is totally disabled.

Employee Affirmation

I affirm that all information submitted as a part of, and in support of, this application is complete and correct, including the student information section of the application, and understand that any intentionally false declaration may result in disciplinary action up to and including termination of employment at Indiana University.

Employee's signature: