2018-2019 Merit Scholarship
Reinstatement Request
Office of Student Financial Aid
1021 Dulaney Valley Road
Baltimore, Maryland 21204-2794
P: 410-337-6141
F: 410-337-6504
E: finaid@goucher.edu
INSTRUCTIONS: Complete the information below and submit this form along with documentation to the
financial aid office. Requests are usually by committee, so please allow at least 3 weeks for a response.
1. STEP ONE: Tell us about yourself.
____________________________ _____________________ __________________
Student Last Name Student First Name Goucher ID Number
____________________________ _____________________ _______________________
E-mail Daytime Phone Number Evening Phone Number
2. STEP TWO: Tell us why you failed to meet the GPA requirement for your merit scholarship.
Death of a relative. Please provide name and relationship to you:
____________________________________________________________________
Injury or illness of student or relative.
Other special circumstance beyond the student’s control.
Please explain briefly (If additional space is needed please attach a separate written explanation):
3. STEP THREE: Tell us what has changed in your situation that will allow you to complete the next
semester successfully.
Please explain briefly (If additional space is needed please attach a separate written explanation):
4. STEP FOUR: If possible, provide supporting documentation for the information you stated in Steps 2
and 3. Please submit this form with all supporting documentation as a single package.
5. STEP FIVE: Sign and date the following statements of understanding:
The student will be notified via email of the appeal decision.
If the request is denied a student may regain eligibility if they meet the GPA requirement in future
semesters.
By signing this form, I certify that I understand all of the above and that all information reported on this form & within the enclosed
documentation is complete & correct.
_____________________________________________ _____________________________
Student Signature Date
(ELECTRONIC SIGNATURES NOT ACCEPTED. Please print, sign in ink, then mail, fax, or scan and e-mail.)