SWANSON SCRIP ORDER FORM Order Form due FRIDAY MAY 20TH Please check ONE delivery option: Hold in Office for pick up ______Release to child* ______* Order must include signed Waiver of Responsibility form, or it must be on file at Swanson office

Name: Child's Name

Email: Child's Grade/Teacher

Phone # Text #

Product % Qty Total Product % Qty Total Apparel & Accessories Dining - Casual/Fine Athleta $25___ $100___ 14.0% $ - Joe's Seafood Steak & Stone Crab $25 12.0% $ - Aerie $25 10.0% $ - Mason Street Grill $25___ $100___ 9.0% $ - Aeropostale $25 10.0% $ - McCormick & Schmick's $25 ___ $100 ___ 9.0% $ - American Eagle Outfitters $25 10.0% $ - Noodles & Co. $10 8.0% $ - Brooks Brothers $25 16.0% $ - Outback/Carrabas/Bonefish $10__ $25__ 8.0% $ - Burlington Coat Factory $25 8.0% $ - P.F. Chang's $25 8.0% $ - Buckle $25 8.0% $ - Panera Bread $10 ___$25 ___ 9.0% $ - Casual Male XL $25 9.0% $ - Rainforest Café $25 __ $100___ 9.0% $ - Claire's $10 9.0% $ - Red Lobster/Olive Garden $25 9.0% $ - Crazy 8 $25 13.0% $ - Red Robin $25 9.0% $ - Dress Barn $25 8.0% $ - Ruby Tuesday's $25 8.0% $ - Express $10 10.0% $ - Ruth's Chris Steak House $50 10.0% $ - Famous Footwear $25 8.0% $ - Texas Roadhouse $25 8.0% $ - Finish Line $25 10.0% $ - TGI Fridays $25 9.0% $ - Foot Locker $25 9.0% $ - Miller Time $25___ $100___ 9.0% $ - Gap $25 ___ $100 ___ 14.0% $ - Dining - On the Go Gymboree $25 13.0% $ - Arby's $10 8.0% $ - J Crew $25 13.0% $ - $10 12.0% $ - Land's End $25 ___ $100 ___ 16.0% $ - Bruegger's Bagels $10 7.0% $ - Limited $25 9.0% $ - $10 10.0% $ - Men's Wearhouse $25 8.0% $ - $10 8.0% $ - Old Navy $25 ___ $100 ___ 14.0% $ - Cousins $10 9.0% $ - Payless Shoes $20 13.0% $ - $10 3.0% $ - Shoe Carnival $25 5.0% $ - Dunkin Donuts/Baskin Robbins $10__$25_ 3.0% $ - Talbot's $25 13.0% $ - Einstein Bagels $10 10.0% $ - The Children's Place $25 12.0% $ - Fazoli's $25 7.0% $ - Department Stores / Discount Stores Great Harvest Bread $10 6.0% $ - Boston Store _$25 or_$100 8.0% $ - Hardees $10 5.0% $ - JCPenney $25 ___ $100 ___ 5.0% $ - Honey Baked Ham $25 12.0% $ - Kohl's $25 ___ $100 ___ 4.0% $ - Domino's $10 8.0% $ - Macy's $25 ___ $100 ___ 10.0% $ - Ross Stores $25___ 8.0% $ - $25 8.0% $ - Sam's Club $25 ___ $100 ___ 2.5% $ - Papa John's $10 8.0% $ - Sears $25___ $100 ___ 4.0% $ - Papa Murphy's Pizza $10 8.0% $ - Target $10___$25___ $50___ 2.5% $ - Peet's Coffee & Tea $20 8.0% $ - TJ Maxx/Marshall's $25 ___ $100___ 7.0% $ - $10 8.0% $ - Wal-Mart $25___ $100 ___ 2.5% $ - Qdoba $25 7.0% $ - Stein Mart $10 7.0% $ - Starbuck's $5___ $10 ___ $25 ___ 7.0% $ - Dining Casual $10___ $50 ___ 6.0% $ - Applebee's $25___ $50 ___ 8.0% $ - Wendy's $10 4.0% $ - Bravo! Cucina Italiana $25 12.0% $ - Travel Buca di Beppo $25 8.0% $ - AVIS Auto Rentals $50 8.0% $ - Buffalo Wild Wings $10 __ $25 __ 8.0% $ - Disney $25___ $100___ 2.0% $ - $25 8.0% $ - Hotels.com $100___ 6.0% $ - Cheesecake Factory $25 8.0% $ - Hyatt Hotels $50 __ $100__ 9.0% $ - Chuck E Cheese $10 9.0% $ - Royal Caribbean $100 13.0% $ - Cracker Barrel $10___$25___ 13.0% $ - Timber Ridge Lodge $25 ___ $100 ___ 9.0% $ - Dave & Buster's $25 7.0% $ - Well Spa at Grand Geneva $25 __ $100 __ 9.0% $ - Denny's $10 8.0% $ - SpaFinder Wellness 365 $25___ $50___ $100 12.0% $ - Fleming's Steakhouse $25__ $50__ 8.0% $ - # Items Amount Fuddruckers $25__ 8.0% $ - Totals This Page $ - Maggiano's $25___ $50__ 11.0% $ - Totals Second Page $ - Totals This Order $ - Swanson Scrip Order Form - Page 2 Product % Qty Total Electronics & Office Best Buy $25 ___ $100 ___ 4.0% $ - Office Max/Office Depot $25 5.0% $ - Staples $10 5.0% $ - Product % Qty Total Online & Mail Order Amazon.com $25 ___ $100 ___ 3.0% $ - American Girl $25 ___ $100 ___ 9.0% $ - Groupon.com $25 7.0% $ - iTunes $15 ___ $25 ___ 5.0% $ - LL Bean $25 $100___ 16.0% $ - Entertainment Oriental Trading Co. $25 9.0% $ - Overstock.com $25 8.0% $ - AMC Theaters $10__ $25___ 8.0% $ - Peapod Online Grocery $25 __ $50 __ 4.0% $ - Loew's Theaters $10___ $25__ 8.0% $ - Shutterfly $25 card 9.0% $ - Barnes & Noble $10 ___ $25 ___ 9.0% $ - Under Armour $25 11.0% $ - Xbox Live $15__ $25__ $50___ 6.0% $ - Marcus Theatres $25 9.0% $ - Zappos $25 ___$100 ___ 8.0% $ - Service & Specialty Retailers 13.0% $ Bath&Body Works $10 ___ $25 ___ 13.0% $ - Gas & Auto Advance Auto Parts $25 7.0% $ - Build-A Bear Workshop $25 8.0% $ - Avis Car Rental $50 8.0% $ - CVS Pharmacy $25 6.0% $ - BP Gas Stations $50 ___ $100 ___ 1.5% $ - $ - GNC $25 8.0% $ - Exxon/Mobil $50 (All States) 1.0% $ - Great Clips $25 8.0% $ - Jiffy Lube $30 8.0% $ - Guitar Center $25 4.0% $ - Kwik Trip $25 ___ $50 ___ 4.0% $ - Hallmark $25 4.0% $ - Shell $25___ $50___ 2.0% $ - JoAnn Fabrics $25 6.0% $ - Speedway/SA $25 ___$100 ___ 4.0% $ - Michael's $25 4.0% $ - SuperAmerica $25 ___ $100 ___ 4.0% $ - PetSmart $25 4.0% $ - Regis Salons $25 8.0% $ - Grocery Sally Beauty $25 12.0% $ - Meijer $10__ $25__ $50__ 3.0% $ - Sephora $20 5.0% $ - Pick N Save/Metro $25 ___ $50 ___ 4.0% $ - Sunglass Hut $25 12.0% $ - Sam's Club $10___ 2.5% $ - Supercuts $25 8.0% $ - Sendik's Food Market$25___ $100___ 4.0% $ - Toys R Us/Babies R Us $20 3.0% $ - Sentry Foods $10 ___ $50___ 3.0% $ - ULTA $25 4.0% $ - Whole Foods $25 __ $100___ 3.0% $ - Walgreens $25 ___ $100 ___ 6.0% $ - Home Décor Well Spa at The Pfister $25 __ $100 __ 9.0% $ - Bed Bath & Beyond $25 __ $100__ 7.0% $ - Sporting Goods 9.0% $ Container Store $25 ___ $100__ 9.0% $ - Bass Pro Shops $25 ___ $100 ___ 9.0% $ - Crate & Barrel $25 ___ $100 ___ 8.0% $ - Champs Sports $25 ___ 9.0% $ - Pier 1 $25 9.0% $ - Cabela's $25 __ $100 ___ 11.0% $ - Pottery Barn $25___ $100 ___ 8.0% $ - Dick's Sporting Goods $25 $100___ 8.0% $ - Williams-Sonoma $25 $100___ 8.0% $ - Dunham's $25 8.0% $ - HomeGoods $25__ $100___ 7.0% $ - Columbia Sportswear $50___ 12.0% $ - Home Improvement Gander Mountain $25 8.0% $ - Ace Hardware $25 ___ $100 ___ 4.0% $ - Golfsmith $10 8.0% $ - Home Depot $25 ___ $100 ___ 4.0% $ - REI $25 8.0% $ - Lowe's $25 ___ $100 ___ 4.0% $ - Menard's $25 ___ $100 ___ 3.0% $ - Miscellaneous & Write-In

Gift Card Wrapper -10 Pack $2.00 10.0% $ - Cheryl's Cookies $10 12.0% $ - 1-800-Flowers $50 12.0% $ - # Items $ - Totals This Page $ -