SCRIP Order Submission
You can use this form to submit a SCRIP order which we can prepare for you before you arrive in the office. Please give us a couple hours before you come to pick up your order, as it will take a little time to prepare your order. Payment can be made when you pick up your order, and is required before receiving your order.
Your name *
Your answer
Phone Number *
Your answer
Where will you pick up your SCRIP? *
Where should we apply the benefit? (Type family name into "Other", if applying to tuition) *
Aeropostale (7%)
1
2
3
4
5
Zero - Clicked by accident
$25
Amazon (2.25%)
1
2
3
4
5
Zero - Clicked by accident
$25
$100
American Eagle Outfitters (10%)
1
2
3
4
5
Zero - Clicked by accident
$25
Applebee's (8%)
1
2
3
4
5
Zero - Clicked by accident
$25
Arby's (8%)
1
2
3
4
5
Zero - Clicked by accident
$10
Baker's Square (8%)
1
2
3
4
5
Zero - Clicked by accident
$25
Barnes & Noble (9%)
1
2
3
4
5
Zero - Clicked by accident
$10
Bath & Body Works (13%)
1
2
3
4
5
Zero - Clicked by accident
$10
$25
Bed, Bath & Beyond (7%)
1
2
3
4
5
Zero - Clicked by accident
$25
Best Buy (6%)
1
2
3
4
5
Zero - Clicked by accident
$25
Beth's Twin Bluffs Café (5%, please write your Gift Certificate amount and how many Certificates you would like)
Your answer
BP Gas Stations (1.5%)
1
2
3
4
5
Zero - Clicked by accident
$50
Buckle (8%)
1
2
3
4
5
Zero - Clicked by accident
$25
Buffalo Wild Wings (13%)
1
2
3
4
5
Zero - Clicked by accident
$25
Cabela's (8%)
1
2
3
4
5
Zero - Clicked by accident
$25
$100
Caribou Coffee (6%)
1
2
3
4
5
Zero - Clicked by accident
$10
Chipotle (10%)
1
2
3
4
5
Zero - Clicked by accident
$10
Claire's (9%)
1
2
3
4
5
Zero - Clicked by accident
$10
Cub Foods (4%)
1
2
3
4
5
Zero - Clicked by accident
$25
Culver's (5%)
1
2
3
4
5
Zero - Clicked by accident
$10
Dairy Queen (5%)
1
2
3
4
5
Zero - Clicked by accident
$5
$10
$20
Dick's Fresh Market (2%)
1
2
3
4
5
Zero - Clicked by accident
$25
$50
$100
Eagle's Nest Coffee (10%)
1
2
3
4
5
Zero - Clicked by accident
$5
$10
$20
Fazoli's (7%)
1
2
3
4
5
Zero - Clicked by accident
$25
Fleet Farm (5%)
1
2
3
4
5
Zero - Clicked by accident
$10
$25
$100
Fresh Wok (5%)
1
2
3
4
5
Zero - Clicked by accident
$10
$25
GAP / Banana Republic / Old Navy (9%)
1
2
3
4
5
Zero - Clicked by accident
$25
Hill's Hardware Hank (5%)
1
2
3
4
5
Zero - Clicked by accident
$10
$25
$100
Home Depot (5%)
1
2
3
4
5
Zero - Clicked by accident
$25
HyVee (3%)
1
2
3
4
5
Zero - Clicked by accident
$10
$25
$100
Interstate Building Supply (3%)
HyVee (3%)
1
2
3
4
5
Zero - Clicked by accident
$10
$25
$100
iTunes (5%)
1
2
3
4
5
Zero - Clicked by accident
$10
$15
JCPenney (5%)
1
2
3
4
5
Zero - Clicked by accident
$25
$100
Kohls (4%)
1
2
3
4
5
Zero - Clicked by accident
$25
Kwik Trip (5%)
1
2
3
4
5
Zero - Clicked by accident
$5
$10
$25
$50
$100
$200
Land's End (16%)
1
2
3
4
5
Zero - Clicked by accident
$25
Lowe's (4%)
1
2
3
4
5
Zero - Clicked by accident
$25
$500
Macy's (10%)
1
2
3
4
5
Zero - Clicked by accident
$25