York University Graduate Students' Association Opt-In Application: Fall 2025

York University Graduate Students' Association

Health and Dental Plan Opt-In Form: Fall 2025
THIS OPT-IN FORM IS FOR GRADUATE STUDENTS ONLY!

Coverage period: September 1, 2025 to August 31, 2026.

The Fall opt-in period is open September 1 until October 31, 2025.

The YUGSA Health and Dental plan is mandatory for all full-time graduate students who do not have alternate coverage. They will be automatically enrolled in the plan and the GSA healthcare charge will appear in their student accounts in September. This charge is separate and in addition to tuition. They may opt-in their dependents to the plan using this form.

Part-time students can also join the plan and opt-in their dependents by using this form.

Approved applications will be processed in early November 2025. Once you are activated on the plan, you will receive an activation email that will include information and instructions on using your plan and how to make claims. Your coverage will be backdated to September 1, 2025. If you have any questions regarding your enrollment in the plan or need help with the opt-in process, please contact health@yugsa.ca during the opt-in period for assistance. Please contact us before the opt-in deadline to ensure that we can assist you. We will not be able to do so if the deadline has passed.
Student Number: *
Full Name*

First NameLast Name
Date of Birth*

YearMonthDay
Gender Identity*
As indicated on your provincial health card or UHIP card
Phone Number*
Email*
Address*

Street Address

Street Address Line 2

CityProvince

Postal Code
Are you a full-time student or a part-time student?*

I am a full-time student.I am a part-time student.
As a full-time student, I would like to:*

Opt-in 1 dependent: $519.36Opt-in 2 or more dependents: $807.24
As a part-time student, I would like to:*

Opt-in myself: $1055.92Opt-in myself ($1055.92) and 1 dependent ($1073.76): $2129.68Opt-in myself ($1055.92) and 2 or more dependents ($1,667.52): $2723.44

Dependent Information (1 dependent)

You have selected to opt-in 1 dependent. Fill in your dependent's information if you are opting-in your common-law partner/spouse or child. **the additional person must be dependent of the student, which include common law partner/spouse and dependent children. All dependent children must be under the age of 21 unless enrolled in post-secondary school, full-time, then up to age 25.
Dependent Relationship to Student

Spouse or Common Law PartnerChild
Dependent Full Name

First NameLast Name
Dependent Date of Birth

MonthDayYear
Dependent Gender Identity
As indicated on their provincial health card or UHIP card.

Dependents Information (2 dependents or more)

Your have selected to opt-in 2 or more dependents. Fill in your dependents' information if you are opting-in your common-law partner/spouse or children. **the additional persons must be dependent of the student, which include common law partner/spouse and/or dependent child(ren). All dependent children must be under the age of 21 unless enrolled in post-secondary school, full-time, then up to age 25. Complete up to 5 dependents. If you have more than 5 dependents to opt-in, please email health@yugsa.ca.
Note: If you are opting-in your spouse/common law partner, you must enter their details in the Dependent #1 fields. If you are not opting-in a spouse/common law partner, select child and enter your first child's details.
Dependent #1 Relationship to Student

Spouse or Common Law PartnerChild
Dependent #1 Full Name

First NameLast Name
Dependent #1 Date of Birth

MonthDayYear
Dependent #1 Gender Identity
As indicated on their provincial health card or UHIP card.
Dependent #2 Relationship to Student

Child
Dependent #2 Full Name

First NameLast Name
Dependent #2 Date of Birth

MonthDayYear
Dependent #2 Gender Identity
As indicated on their provincial health card or UHIP card.
Dependent #3 Relationship to Student

Child
Dependent #3 Full Name

First NameLast Name
Dependent #3 Date of Birth

MonthDayYear
Dependent #3 Gender Identity
As indicated on their provincial health card or UHIP card.
Dependent #4 Relationship to Student

Child
Dependent #4 Full Name

First NameLast Name
Dependent #4 Date of Birth

MonthDayYear
Dependent #4 Gender Identity
As indicated on their provincial health card or UHIP card.
Dependent #5 Relationship to Student

Child
Dependent #5 Full Name

First NameLast Name
Dependent #5 Date of Birth

MonthDayYear
Dependent #5 Gender Identity
As indicated on their provincial health card or UHIP card.

Your Opt-In Coverage

Based on your selections, your coverage is as summarized:
Opt-In Coverage Selected:
Hidden: FT Couple $519.36
Couple coverage ($519.36): I am a full-time student and have been charged $519.36 by the University for myself and am opting-in 1 dependent.
Hidden: FT Family $807.24
Family coverage ($807.24): I am a full-time student and have been charged $807.24 by the University for myself and am opting-in 2 or more dependents.
Hidden: PT Single $1055.92
Single coverage ($1055.92): I am a part-time student and am opting-in only myself.
Hidden: PT Couple $2129.68
Couple coverage ($2129.68) : I am a part-time student and am opting-in myself ($2129.68) and 1 dependent ($2129.68).
Hidden: PT Family $2723.44
Family coverage ($2723.44): I am a part-time student and am opting-in myself ($2723.44) and 2 or more dependents (($2723.44).
Hidden: Total Opt-In Cost (Logic Field)
Hidden: Total Opt-In Cost (Calculation Field)

Total Opt-In Charge

CADYUGSA Opt-In Fall 2025

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

By clicking the below "Submit Opt-in Application and Make Payment" button, you:
1. Declare that you are a York University graduate student who is eligible to opt-in to the York University Graduate Students' Association (YUGSA) health and dental plan and that any additional persons included in this application are a common law partner/spouse and/or dependent child(ren) which must be under the age of 21 unless enrolled in post-secondary school, full-time, then up to age 25;
2. Grant the YUGSA authorized partner, the National Student Health Network, to immediately charge your provided payment card with your selected opt-in plan value;
3. Agree that your application will be reviewed for accuracy and will be verified with York University enrolment data;
4. Understand that this is an application to opt-in to the YUGSA health and dental plan and that enrolment is not guaranteed nor instantaneous.
Should be Empty:

York University Graduate Students' Association

Dependent Information (1 dependent)

Dependents Information (2 dependents or more)

Your Opt-In Coverage