Scrip Order Form Name : Phone

CEDAR PARK CHRISTIAN SCHOOL CAMPUS Scrip Order Form Name : Phone : Student Name : Grade/Teacher : Delivery Options : Send home with Student (Sign Release below) Pick up at Finance Office Today's Date : ____ / ____ / ___ Parent Signature for Release: RESTAURANTS (% Profit) Value Qty Total RESTAURANTS (% Profit) Value Qty Total Anthony's (8%) $25 Olive Garden / Red Lobster (7%) $25 Applebee's (7%) $25 $50 Outback Steak/Bonefish Grill (7%) $25 $50 Arby's (7%) $10 P.F. Chang's (7%) $25 Big Fish Café (8%) $25 $100 Panera Bread (7%) $10 $25 Black Angus (10%) $25 Papa John's (7%) $10 Buca di Beppo (7%) $25 Papa Murphy's (7%) $10 Burger King (4%) $10 Peet's Coffee & Tea (7%) $20 California Pizza Kitchen (6%) $10 Pizza Hut (7%) $10 Cheesecake Factory (4%) $25 Qdoba Mexican Grill (6%) $25 Chili's (9%) $25 $50 Rainforest Café (8%) $25 Chipotle (9%) $10 Red Robin (7%) $25 Chuck E. Cheese (7%) $10 Ruth Cris Steakhouse (9%) $50 Claim Jumper (7%) $25 $100 Starbucks (6%) $10 $25 Coldstone Ice Creamery (7%) $10 Subway (4%) NEW $10 $50 Dairy Queen (3%) $10 Taco Bell (4%) $10 Denny's (6%) $10 Wendy's (4%) $10 Domino's Pizza (7%) $10 Great Harvest Bread Co (5%) $10 Jack In The Box (4%) $10 Little Caesars (7%) $20 Maggianos Little Italy (9%) $25 $50 $25 $50 Subtotal : Subtotal : DUE DATES FOR WINTER/SPRING Front Page Subtotal: $ MONDAYS Back Page Subtotal: $ Jan 8, Jan 22, Feb 5, Feb 26, Mar 12, Mar 26, Apr 9, Apr 23, May 7, May 21, June 4 Order Total: $ General Information: 1. Orders are due 3:00PM on the due date. Credits or Past Due: $ 2. If more than one denomination is available, please circle your desired amount. 3. Protect your scrip and be aware of expiration dates. Check Amount: $ 4. Respect the change policies of all the merchants. (Payable to CPCS) Participating retailers and discounts are subject to change without notice. To view Nationwide Merchant List and write-in special orders in highlighted fields above -- Visit: www.shopwithscrip.com GROCERY & AUTO (% Profit) Value Qty Total GROCERY & AUTO (% Profit) Value Qty Total Albertsons (3%) $25 $100 Arco (1.5%) $50 $50 $100 QFC & Fred Meyer (4%) $25,$50 $100 BP Gas (1.5%) $50 Safeway (3%) $25 $100 Shell Gas (2.0%) $25 $50 $100 Whole Foods (3%) $25 $100 RETAIL & SPECIALTY (% Profit) Value Qty Total RETAIL & SPECIALTY (% Profit) Value Qty Total Ace Hardware (4%) $25 Lands' End (13%) $25 $100 Amazon.com (2.5%) $25 $100 LL Bean (12%) $25 $100 AMC Theatres (6%) $25 Lowe's (3%) $25 $100 AMC Theatres Single Admit (9%) $10 $12 Macy's / Filene's (8%) $25 $100 American Eagle Outfitters (8%) $25 Men's Wearhouse (7%) $25 American Girl (8%) $25 $100 Michael's (4%) $25 Athleta (11%) $25 $100 Neiman Marcus (10%) $50 Auto Zone (7%) $25 Nike (10%) $25 Barnes & Noble / B. Dalton (7%) $10 $25 Nordstroms (5%) $25 $100 Bath & Body Works (10%) $10 $25 Nordstroms Rack (5%) $25 $100 Bed Bath & Beyond (6%) $25 Office Depot/Office Max (4%) $25 $100 Best Buy (3%) $25 $100 Oriental Trader (8%) $25 Best Western (10%) $25 $100 Osh Kosh (9%) $25 Big 5 Sporting Goods (7%) $25 Overstock.com (7%) $25 Burlington Coat Factory (7%) $25 PetSmart (4%) $25 Build-A-Bear Workshop (7%) $25 Pier 1 Imports (8%) $25 Cabela's (9%) $25 Pottery Barn/Pottery Barn Kids (7%) $25 $100 Claire's (7%) $10 Regal Entertainment (7%) $25 Comfort Inn (3%) $50 $100 Regal Single Admit (8%) $10 Crate and Barrel (7%) $25 $100 Regis Salons (7%) ** $25 Dick's Sporting Goods (7%) $25 REI (7%) $25 Disney (2%) $25 $100 Rite Aid (4%) $25 Famous Footwear (7%) $25 Ross Dress for Less (7%) $25 Fandango (3%) Scrip Now Only Sears (4%) $25 $100 Finish Line (9%) $25 See's Candies (15%) 1 Lb Cert. $20 Footlocker (8%) $25 See's Gift Card (8%) $25 GameStop (3%) $25 Sephora (4%) $20 Gap, Banana Rep, Old Navy 10% $25 $100 Shutterfly (8%) $25 GNC (7%) $25 Staples (4%) $25 $100 Great Clips (7%) $25 Talbots (10%) $25 Groupon (6%) $25 Target (2%) $25 $100 Gymboree (10%) $25 T.J. Maxx / Marshalls (6%) $25 $100 Hallmark (4%) $25 Toys-R-Us (3.0%) $20 $100 Home Depot (3%) $25 $100 ULTA (4%) $25 Home Depot (3%) $1000 also avail $500 Walgreens (5%) $25 $100 Itunes (4%) $15 $25 Walmart/Sam's Club (2%) $25 $100 JCPenney (4%) $25 $100 Zappos.com (7%) NEW $25 $100 Jiffy Lube (7%) $30 Jo Ann Fabrics (5%) $25 Kohl's Dept Store (4%) $25 $100 K-Mart (4%) $25 $50 See Shopwithscrip.com for other retailers Subtotal :.

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