5200 N. Lake - Office of the Registrar

Grade/Enrollment Certifications-Greek or Student Organizations/Clubs or
Non-Sanctioned* Sports Teams
UNIVERSITY OF CALIFORNIA, MERCED
Office of the Registrar
5200 N. Lake Rd., Merced, CA 95343 / Phone: (209) 228-7178 / registrar.ucmerced.edu
Circle the item/term you want confirmed (request 1 term at a time:
Requesting Organization
Requesting Representative
Email Address
List your reason for wanting to know GPA (if part of your request):
* Semester GPA:
Fall
Spring
Year:
* Cumulative GPA:
Fall
Spring
Year:
* Both GPAs above:
Fall
Spring
Year:
* Enrollment:
Fall
Spring
Year:
* GPA and enrollment:
Fall
Spring
Year:
Organization Member Roster
1. Print each member's name below. Use an additional form if you have more members than will fit below. If you prefer, attach a typed
copy of the organizations roster. Or, attach the association's/organization's form that may be required.
2. Attach a Permission to Release Education Record (see page 2 of this form) for each student listed below unless student signatures are on an
attached form (waived for Greek organizations if Assistant Director of Student Life signs below).
3. Submit all forms to Laurie Herbrand, Registrar, at the Students First Center with a least three business days' advance notice of when the
information is needed. You will receive an email when information is ready.
Last Name
First Name
Student ID
Sem GPA
Cum GPA Enrollment
___________ ____________ ___________
___________ ____________ ___________
___________ ____________ ___________
___________ ____________ ___________
___________ ____________ ___________
___________ ____________ ___________
___________ ____________ ___________
___________ ____________ ___________
___________ ____________ ___________
___________ ____________ ___________
___________ ____________ ___________
___________ ____________ ___________
Coordinator of Fraternity & Sorority Life Signature _________________________________________ Date ____________________
(for Greek Organizations if no Permission forms)
* Please see the Recreation & Athletics Sports Club Director for Sanctioned Sport Eligibility Certification (for sanctioned club sports terms
see recreation.ucmerced.edu/recreation-athletics)
Print Form
UNIVERSITY OF CALIFORNIA, MERCED
Office of the Registrar
Permission to Release Education Record
5200 N. Lake Rd., Merced, CA 95343 / Phone: (209) 228-7178 / registrar.ucmerced.edu
I give permission for the University of California, Merced to release my
__________________________________________________________________________________________________________________
Education record information to be released
to _____________________________________________________________________________________________
name of organization
for (purpose) ____________________________________________________________________________________
Personal Information
Student Id Number ___________________________________________________ Email Address ___________________________________
Name _____________________________________________________________________________________________________________
Address ___________________________________________________________________________________________________________
City/State/Zip _____________________________________________________________ Phone ___________________________________
Student's Signature ___________________________________________________________ Date ___________________________________