| Last name, Parent First name | Child's Class: | Phone: | Date: | ||||||
| Vendor / Rebate % | $ | Qty | Total | Vendor / Rebate % | $ | Qty | Total | ||
| Grocery: | Other Vendors: | ||||||||
| Food Lion | 5% | 25, 50, 100 | Ace Hardware | 4% | 25, 100 | ||||
| Harris Teeter | 6% | 25, 50, 100 | amazon.com | 4% | 25, 100 | ||||
| Kroger | 5% | 25, 50, 100 | American Eagle Outfitters | 9% | 25 | ||||
| Lowe's Foods | 6% | 25, 50, 100 | Barnes & Noble/B.Dalton | 9% | 10, 25, 100 | ||||
| The Fresh Market | 5% | 25, 50, 100 | Bath & Body Works | 13% | 10, 25 | ||||
| Gas | Bed, Bath & Beyond | 7% | 25 | ||||||
| BP Cash Card | 2% | 50 | Belk | 7% | 25 | ||||
| Exxon/Mobil | 1.5% | 50 | BestBuy | 2% | 25, 100, 250 | ||||
| Sheetz Gas | 3% | 25, 100 | Blockbuster Video | 7% | 10 | ||||
| Shell Debit Card | 1.5% | 25, 100 | Borders/Waldenbooks | 9% | 10, 25 | ||||
| Restaurants | Brier Creek/North Hills Cinema | 8% | 25 | ||||||
| Applebee's | 8% | 25 | Build-A-Bear Workshop | 8% | 25 | ||||
| Arby's | 8% | 10 | Circuit City | 3% | 25, 100 | ||||
| Baskin Robbins | 9% | 2 | Claire's | 9% | 10 | ||||
| Bruegger's Bagels | 5% | 10 | Crate & Barrel | 8% | 25, 100 | ||||
| Burger King | 4% | 10 | CVS Pharmacy | 6% | 25 | ||||
| Champps | 5% | 25 | Dick's Sporting Goods | 5% | 25 | ||||
| Cheesecake Factory | 5% | 25 | Dillard's | 9% | 25, 100 | ||||
| Chili's/Macaroni Grill/On The Border | 11% | 25 | Eddie Bauer | 9% | 25 | ||||
| Chipotle Mexican Grill | 10% | 10 | Express/Structure | 13% | 25 | ||||
| Cold Stone Creamery | 8% | 10 | Gap/Banana Republic/Old Navy | 9% | 25 | ||||
| Cracker Barrel | 9% | 10 | Great Clips | 8% | 25 | ||||
| Domino's Pizza | 5% | 5 | Gymboree | 13% | 25 | ||||
| Dunkin Donuts | 4% | 10 | Home Depot | 3% | 25, 100, 500 | ||||
| Goodberry's | 30% | 10 | ITunes | 4% | 15 | ||||
| Great Harvest Bread Co | 8% | 10 | JC Penney | 5% | 25, 100 | ||||
| Honey Baked Ham | 12% | 10 | J Crew | 13% | 25 | ||||
| KFC | 9% | 5 | Jo-Ann Fabrics | 6% | 20 | ||||
| Michael Dean's,Twisted Fork, | 10% | 10, 25, 50 | K-Mart | 4% | 25, 50 | ||||
| Red Room, Hi5,1705 Prime | 10% | 10, 25, 50 | Kohl's | 5% | 10, 25, 50 | ||||
| The Mash House, Bogart's | 10% | 10, 25, 50 | LL Bean | 15% | 25, 100 | ||||
| Mimi's Cafˇ | 8% | 25 | Land's End **BONUS** | 12% | 25, 100 | ||||
| Outback/Carrabba's/Bonefish Grill | 5% | 25 | Linens & Things | 8% | 25 | ||||
| P.F. Chang's/Pei Wei | 7% | 25 | Lowe's Home Improvement | 4% | 25, 100, 500, 1000 | ||||
| Panera Bread | 9% | 10 | Macy's | 10% | 25, 100 | ||||
| Papa John's Pizza | 8% | 10 | MICHAEL'S | 4% | 25 | ||||
| Pizza Hut | 8% | 10 | OfficeDepot | 4% | 25 | ||||
| Red Lobster/Olive Garden | 9% | 25 | Office Max | 4% | 25 | ||||
| Red Robin | 9% | 10 | Payless Shoes | 13% | 20 | ||||
| Ruth Chris' Steakhouse | 10% | 50 | Pier One Imports | 9% | 25 | ||||
| Ruby Tuesday's | 8% | 25 | Pottery Barn/Williams & Sonoma | 8% | 25, 100 | ||||
| Starbucks | 7% | 10, 25 | Radio Shack | 4% | 25 | ||||
| Stromboli's | 19% | 10, 20 | Regis Hair Salons | 8% | 25 | ||||
| Subway | 3% | 10, 50 | Restoration Hardware | 12% | 25, 100 | ||||
| Sweet Tomatoes | 8% | 10 | Ritz/Wolf Camera | 6% | 25 | ||||
| TGI Friday's | 9% | 25 | Sears | 4% | 25, 100, 250 | ||||
| Wendy's | 4% | 10 | Sephora | 4% | 20 | ||||
| Travel | Shutterfly **BONUS** | 14% | 25 | ||||||
| Bed and Breakfast.com | 10% | 50 | Staples | 5% | 25, 100 | ||||
| Best Western Intl | 12% | 25, 100 | TJ Maxx/Marshalls/Homegoods | 7% | 25, 100 | ||||
| Comfort/Sleep/Quality Inn | 6% | 25, 100 | Talbots | 11% | 25 | ||||
| Disney Gift Card | 2% | 25, 100,1000 | The Children's Place | 12% | 25 | ||||
| Marriott Hotels | 12% | 50, 100, 500 | Walgreens | 2% | 20, 100 | ||||
| WalMart | 2% | 25, 100, 250 | |||||||
| Subtotal Column 1 | $ | Subtotal Column 2 | $ | ||||||
| Grand Total: | $ | ||||||||
| Make checks payable to SRCS HSA, Call Krystin Knox at 570-8882 with any questions | |||||||||
| I will pay for this order with CASH_______CHECK________or CREDIT CARD ($2 service fee)________________ | |||||||||
| I want to receive my SCRIP order in my child's (class_______) Wed Mailer______ or at the school office_____ | |||||||||
| ***********************SCRIP NEWS ON THE BACK OF THIS FORM****************************** | |||||||||