Denver Christian Schools Scrip Order Form Rebates you earn are applied toward your family's tuition. A small % of the rebate is retained for administrative cost of the scrip program. Make checks payable to: Denver Christian Schools  for General Education Fund for Denver Christian Schools Name of Person Ordering Cell Phone Number Family Name w/ Account Number

Grade/Teacher Send with: Order Date Total Order $

Retail Product ** % Qty Total Retail Product (cont) % Qty Total Restaurant Product (cont) % Qty Total Aeropostale $25 7% $ Old Navy $25 / $100 14% $ Honey Baked Ham $25 12% $ Amazon.com $25 / $100 4% $ Payless Shoes $20 13% $ IHOP $25 8% $ AMC Theatres $25/Adult ticket $9.50 7%/10% $ Oriental Trading Co $25 9% $ Jamba Juice $10 7% $ American Eagle Outfitters $25 10% $ PetSmart $25 4% $ KFC $5 8% $ American Girl $100/ $25 9% $ Pier 1 Imports $25 9% $ Landry's Seafood $25 / $100 9% $ Banana Republic $25 / $100 14% $ Pottery Barn & Kids $25 / $100 8% $ Little Cesar's Pizza $20 8% $ Barnes & Noble $10 / $25 / $100 9% $ Regis Salons $25 8% $ Macaroni Grill $25 11% $ Bass Pro Shops $25 / $100 9% $ REI $25 8% $ Maggiano's Little Italy $25 11% $ Bath & Body Works $10 / $25 13% $ $25 4% $ Mimis Cafe $25 8% $ Bed Bath & Beyond $25 / $100 7% $ Ross Dress for Less $25 8% $ Noodle's & Company $10 8% $ Best Buy $25 / $100 / $250 3% $ Sally Beauty Supply $25 12% $ Old Chicago $25 6% $ $25 8% $ Sears $25 / $100 / $250 4% $ Olive Garden $25 9% $ Build-A-Bear Workshop $25 8% $ Sephora $20 4% $ On The Border $25 11% $ Cabela's $25 / $100 11% $ Shell Gasoline $25 / $50 / $100 2.5% $ Outback Steakhouse $25 8% $ Children's Place $25 12% $ Shutterfly $25 9% $ P.F. Chang's / PeiWei $25 8% $ Claire's $10 9% $ $25 / $100 8% $ Panera Bread $10 / $25 9% $ Container Store $25 / $100 9% $ Staples $25 / $100 5% $ Papa John's $10 8% $ Crate and Barrel $25 / $100 8% $ T.J. Maxx $25 / $100 7% $ Papa Murphy's Pizza $10 8% $ Dick's Sporting Goods $25 / $100 8% $ Tagawa Garden Center $25 20% $ Pizza Hut $10 8% $ Dillard's $25 / $100 9% $ Talbots $25 13% $ Qdoba Mexican Grill $25 7% $ DSW $25 9% $ Target $25 / $100 2% $ Quiznos $10 10% $ Eddie Bauer $25 10% $ Toys R Us $20 1.5% $ Red Lobster $25 9% $ Express $25 10% $ Ulta Salon $25 4% $ Red Robin $25 9% $ Finish Line $25 10% $ United Artist Theatres $25 8% $ Rock Bottom Restaurant $25 6% $

Gamestop $25 3% $ Walgreens $25 / $100 6% $ See's Candies $16.90 / $25 20%9% $ Gap $25 / $100 14% $ Walmart /Sam's $25 / $100 / $250 2.5% $ Smashburger $10 10% $ Great Clips $25 8% $ Williams-Sonoma $25 / $100 8% $ Steak 'n Shake $10 8% $ Groupon $25 7% $ Starbucks $10 / $25 7% $ Gymboree $25 13% $ Restaurant Product % QTY Total Subway $10 / $50 3% $ Home Depot $25 / $100 / $500 / $1000 4% $ Applebee's $25 / $50 8% $ Sweet Tomatoes $25 8% $ Hyatt Hotels $50 / $100 9% $ Arby's $10 8% $ Taco Bell $10 5% $ iTunes® $15 / $25 5% $ Boston Market $10 12% $ Roadhouse $25 8% $ J. Crew $25 13% $ Burger King $10 4% $ TGI Friday's $25 9% $ JCPenney $25 / $100 5% $ Pizza $10 4% $ Wendy's $10 4% $ Jo-Ann Fabrics $25 6% $ Carl's Jr. $10 5% $ Yard House $25 8% $ *Kohl's (Denver Christian) $25 / $100 5% $ Cheesecake Factory $25 5% $ L.L.Bean $25 / $100 16% $ Chili's Grill & Bar $25 11% $ Grocery Product % QTY Total Lands' End $25 / $100 16% $ Chipotle Mexican Grill $10 10% $ Albertsons $25 / $100 4% $ Limited $25 9% $ Chuck E. Cheese $10 8% $ King Soopers $25 / $100 5% $ Lowe's $20 / $25 / $100 / $500 / $1000 4% $ Cold Stone Creamery $10 8% $ King Soopers Reloadable (DC) $10 5% $ Macy's $25 / $100 10% $ Dave & Buster's $25 13% $ Safeway (Denver Christian) $25/ $100 5% $ Marriott Hotels $50/ $100 / $500 8% $ Denny's $10 7% $ Safeway Reloadable (DC) $10 *** 5% $ Michaels $25 4% $ Domino's Pizza $10 8% $ Sprouts $25/ $50 / $100 5% $ Nike $25 12% $ Einstein Bro. Bagel $10 10% $ Tony's Meats $25 7% $ Office Depot $25 / $100 4% $ Great Harvest Bread $10 6% $ Vitamin Cottage $25 / $100 5% $ Office Max $25 / $100 5% $ Harry & David $25 10% $ Whole Foods $25 / $100 3% $ ***Original Safeway $10 Reloadable Card is 3%; subsequent reloads are at 5%. Notes: **Limited time bonus offers can be viewed at www.shopwithscrip.com under specials Check # Total $ *Kohl's - scrip can pay Kohl's charge card balance Created: 1/8/2015