Shaker Heights City Schools

							       Shaker Heights City School District
       15600 Parkland Drive
       Shaker Heights, OH 44120
       (216) 295-1400
       (216) 295-4340 fax


               SHAKER HEIGHTS CITY SCHOOL DISTRICT
        Express Scripts Prescription Drug Benefit Plan Enrollment Form
Primary Cardholder Information                              Effective Date________
 Name: ______________________________________            ________________________
 Associate ID number (or SSN):

 Address: ______________________________________________________________________

 City: ________________________ State: __________ Zip Code: _______________________
 Date of Birth (mm/dd/yyyy):                              Gender: Male   Female

Family Members to be covered by the Plan
 Name:                                                   ________________________
 Relationship to Primary Cardholder:
 Social Security Number:
 Date of Birth (mm/dd/yyyy):                              Gender: Male   Female

 Name:                                                   ________________________
 Relationship to Primary Cardholder:
 Social Security Number:
 Date of Birth (mm/dd/yyyy):                              Gender: Male   Female

 Name:                                                   ________________________
 Relationship to Primary Cardholder:
 Social Security Number:
 Date of Birth (mm/dd/yyyy):                              Gender: Male   Female

 Name:                                                    _______________________
 Relationship to Primary Cardholder:
 Social Security Number:
 Date of Birth (mm/dd/yyyy):                              Gender: Male   Female




 ___________________________________________            Date:__________________
 Signature of primary cardholder