Winter Registration

THIS FORM IS FOR PART-TIME FALL 2026 GRADUATE STUDENTS ONLY!

Coverage period: Sept. 01, 2026 to August 31, 2027.

Opt-in period: Sept. 01 until October 31, 2026.

Part-time students must submit this form as an initial step to opt themselves (or their dependents) in the plan. Once the submission is complete, you will be contacted by Telus Health to complete the next steps.
Member Information
Student Union
Last Name
First Name
Registration status
Gender
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
E-Mail Address (York Account)
Date of Application

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature (Use mouse to draw,or use touch/pen on tablets)
Signature (Type in Your Name)
Email
example@example.com
Should be Empty: