SCRIP Order Form

$CRIP Order Form Name:___________________________________________________ Lodi Academy Phone #:_________________________Today’s Date:_____________ 1230 S. Central Avenue, Lodi, CA 95240 Student to credit:___________________________________________ 209-368-2781 ~ www.lodiacademy.net Revised August 28, 2017 75% of the profits go to a designated student’s $crip account to be used toward any school- Changes & additions have been made to retailers. related expenses not associated with tuition. Ideas for use are Bible Retreats, Sports Fees, History Tour or Senior Class Trip. The other 25% goes to the Parent-Teacher Organization to You can use your $crip money towards many things at the academy, cover the shipping and handling costs of orders. Funds left when a student graduates or Bible Retreat, Sports Fees, History Tour or Music Tour to name a few. withdraws go to the Parent-Teacher Organization. Automotive/Gas Restaurants/Food (Continued) Vendor % # Price Total Filled Vendor % # Price Total Filled Arco 1.5 $50 Dennys 7 $10 Arco 1.5 $100 Domino’s Pizza 8 $10 Shell 2 $50 El Pollo Loco 6 $10 Grocery IHOP 8 $25 Vendor % # Price Total Filled Islands 8 $25 Food 4 Less 3 $20 Jack in the Box 4 $10 Food 4 Less 3 $50 Juice It Up 10 $10 Food 4 Less 3 $100 Little Caesar’s 8 $20 Raley’s 4 $25 Macaroni Grill 11 $25 Raley’s 4 $100 Mimi’s Café 8 $25 Safeway 4 $25 Noodles & Company 8 $10 Safeway 4 $100 Olive Garden 9 $25 Sam’s Club 2.5 $25 On The Border 11 $25 Sam’s Club 2.5 $100 Outback Steakhouse 8 $25 Save Mart / Smart Foods 2 $25 Panda Express 8 $25 Save Mart / Smart Foods 2 $100 PF Chang 8 $25 Smart & Final 3 $25 Panera Bread 8 $10 Sprouts 5 $25 Panera Bread 8 $25 Whole Foods Market 3 $25 Papa John’s Pizza 8 $10 Whole Foods Market 3 $100 Papa Murphys Pizza 8 $10 Restaurants/Food Pizza Hut 8 $10 Vendor % # Price Total Filled Rainforest Café 9 $25 Applebee’s 8 $25 Red Robin 8 $25 Blaze Pizza 10 $25 See’s Candies 20 $19.90 Burger King 4 $10 Smashburger 10 $10 California Pizza Kitchen 8 $25 Starbuck’s 7 $10 Carl’s Jr. 5 $10 Starbuck’s 7 $25 Cheesecake Factory 5 $25 Subway 6 $10 Chevy’s 8 $25 Taco Bell 5 $10 Chili’s/Macaroni Grill 11 $25 Texas Roadhouse 8 $25 Chipotle 10 $10 TGI Friday’s 9 $25 Claim Jumper 9 $25 Wendy’s 4 $10 Coldstone Creamery 8 $10 Del Taco 7 $10 Retail/Other Retail/Other (Continued) Vendor % # Price Total Filled Vendor % # Price Total Filled Amazon.com 2.5 $25 Macy’s 10 $25 American Eagle 10 $25 Macy’s 10 $100 Banana Republic 14 $25 Marshall’s/T.J. Maxx 7 $25 Barnes & Noble/B. Dalton 8 $10 Marshall’s/T.J. Maxx 7 $100 Barnes & Noble/B. Dalton 8 $25 Michaels 4 $25 Bass ProShop 9 $25 Nordstrom 6 $25 Bath & Body Works 13 $10 Old Navy 14 $25 Bath & Body Works 13 $25 Payless Shoe Source 13 $20 Bed Bath & Beyond 7 $25 Pep Boys 4 $20 Best Buy 47 $25 PetSmart 5 $25 Best Buy 4 $100 Pier One 9 $25 Big 5 Sporting Goods 8 $25 REI Sporting Goods 8 $25 Crate and Barrel 8 $25 Rite Aid 4 $25 CVS Drugs 6 $25 Ross Dress for Less 8 $25 Dicks Sporting Goods 8 $25 Sally Beauty Supply 12 $25 Dicks Sporting Goods 8 $100 Sears 4 $25 Dillards 9 $25 Sears 4 $100 Express/Structure 10 $25 Sephora 5 $20 Famous Footwear 8 $25 Staples 5 $25 Footlocker 8 $25 Target 2.5 $25 Gap/Gap Kids/Baby Gap 14 $25 Target 2.5 $50 Gymboree 13 $25 Target 2.5 $100 Home Depot 4 $25 Toys “R” Us 3 $20 Home Depot 4 $100 ULTA 4 $25 Home Depot 4 $500 Wal-Mart – Sam’s Club 2.5 $25 HomeGoods 7 $25 Wal-Mart – Sam’s Club 2.5 $100 iTunes 5 $15 Walgreen’s 6 $25 iTunes 5 $25 Walgreen’s 6 $100 JC Penney 5 $25 Williams-Sonoma 8 $25 JC Penney 5 $100 Williams-Sonoma 8 $100 J Crew 13 $25 JoAnn’s 6 $25 Kohl’s 4 $25 Kohl’s 4 $100 Total Side One: _____________________________ Land’s End 16 $25 Total Side Two: ____________________________ Land’s End 16 $100 Lowe’s Home 4 $25 Grand Total: _____________________________ Lowe’s Home 4 $100 Lowe’s Home 4 $500 Signature of Pick-up: _____________________________ OFFICE USE ONLY Total: _____________________________________ Date Order Filled: _____________________________ Student Credit (75%) _____________________________ Payment Type: _____________________________ Filled By: ____________________________________ PTO Credit (25%) ________________________________ .

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