Student Dependent Declaration Form - Option 2 | Emergency Services Health

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Option 2: Non-Student Dependent

Student First Name

Membership #

I declare that

The dependent will not be registered as a full-time student by 1 March 2025. However, the dependent is under the age of 25, is not married or in a de-facto relationship and I would like to keep them covered under our policy. I'm aware this may increase the premiums.

Our Member Services Team will provide written confirmation of any changes or updates.

Our Member Services Team will provide written confirmation of any changes or updates.

Please provide any other information that may assist.

The statements made and information provided are true, correct and complete; and

I undertake to inform Emergency Services Health immediately of any change in the circumstances of the above-named dependent; and

I have read and understand Emergency Services Health privacy notice.

Full Name of Person Completing Form

Date