2023 – Winter – Family/Couple Enrolment | Toronto Metropolitan Association of Part-time Students

Please select one of the following:*

Couple enrolment (for spouse/partner or one child) for both Health and Dental: $630.84

Family enrolment (including spouse + three children) for both Health and Dental: $840.48

TMAPS Health and Dental Plan

Benefit Period: January 1, 2025 - August 31, 2025

Part-time undergraduate degree students access coverage for medical expenses such as prescription drugs and dental treatments through TMAPS. These benefits can be extended to a spouse and/or dependent children for an additional fee. To add eligible dependents, complete the sections below and submit the form.

Last Name*

First Name*

Initial*

Gender*

Undisclosed

Female

Male

Date of Birth*

dd/mm/yyyy

Mailing Address*

Phone

Email*

Part-Time Degree Program*

Student Number*

Please note that your Green Shield ID is CSR + Your Student Number -00

Family Information

Please ensure that all information is correct.

How many dependents are you hoping to enrol?*

One

Two

Three

Four

Last Name 1

(suffix -01)

First Name 1

Relationship 1

Gender 1

Undisclosed

Female

Male

Date of Birth 1

(DD/MM/YYYY)

Last Name 2

(suffix -02)

First Name 2

Relationship 2

Gender 2

Undisclosed

Female

Male

Date of Birth 2

(DD/MM/YYYY)

Last Name 3

(suffix -03)

First Name 3

Relationship 3

Gender 3

Undisclosed

Female

Male

Date of Birth 3

(DD/MM/YYYY)

Last Name 4

(suffix -04)

First Name 4

Relationship 4

Gender 4

Undisclosed

Female

Male

Date of Birth 4

(DD/MM/YYYY)

Last Name 5

(suffix -05)

First Name 5

Relationship 5

Gender 5

Undisclosed

Female

Male

Date of Birth 5

(DD/MM/YYYY)

Last Name 6

(suffix -06)

First Name 6

Relationship 6

Gender 6

Undisclosed

Female

Male

Date of Birth 6

(DD/MM/YYYY)

Last Name 7

(suffix -07)

First Name 7

Relationship 7

Gender 7

Undisclosed

Female

Male

Date of Birth 7

(DD/MM/YYYY)

BY COMPLETING THIS FAMILY APPLICATION FORM, YOU AGREE TO THE FOLLOWING:

I confirm that the information provided above is accurate. I understand that the information above is required in order for me to provide the same extended health and dental benefits, as outlined in the benefits plan booklet available online at www.greenshield.ca/studentcentre, excluding tutorial benefits, to my spouse and/or dependent children. I further understand that Accidental Death and Dismemberment benefits offered by ACE INA are for members only and are NOT available to my spouse and/or dependent children. I authorize the use of this information where it is required, and I am aware that this information will not be used in any manner except to administer the plans in accordance with TMAPS policy.

Once eligibility is confirmed, someone in our office will contact you to process the payment and complete your application.