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 *
Phone Number *
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
Clear selection
Amazon (2.25%)
1
2
3
4
5
Zero - Clicked by accident
$25
$100
Clear selection
American Eagle Outfitters (10%)
1
2
3
4
5
Zero - Clicked by accident
$25
Clear selection
Applebee's (8%)
1
2
3
4
5
Zero - Clicked by accident
$25
Clear selection
Arby's (8%)
1
2
3
4
5
Zero - Clicked by accident
$10
Clear selection
Baker's Square (8%)
1
2
3
4
5
Zero - Clicked by accident
$25
Clear selection
Barnes & Noble (9%)
1
2
3
4
5
Zero - Clicked by accident
$10
Clear selection
Bath & Body Works (13%)
1
2
3
4
5
Zero - Clicked by accident
$10
$25
Clear selection
Bed, Bath & Beyond (7%)
1
2
3
4
5
Zero - Clicked by accident
$25
Clear selection
Best Buy (6%)
1
2
3
4
5
Zero - Clicked by accident
$25
Clear selection
Beth's Twin Bluffs Café (5%, please write your Gift Certificate amount and how many Certificates you would like)
BP Gas Stations (1.5%)
1
2
3
4
5
Zero - Clicked by accident
$50
Clear selection
Buckle (8%)
1
2
3
4
5
Zero - Clicked by accident
$25
Clear selection
Buffalo Wild Wings (13%)
1
2
3
4
5
Zero - Clicked by accident
$25
Clear selection
Cabela's (8%)
1
2
3
4
5
Zero - Clicked by accident
$25
$100
Clear selection
Caribou Coffee (6%)
1
2
3
4
5
Zero - Clicked by accident
$10
Clear selection
Chipotle (10%)
1
2
3
4
5
Zero - Clicked by accident
$10
Clear selection
Claire's (9%)
1
2
3
4
5
Zero - Clicked by accident
$10
Clear selection
Cub Foods (4%)
1
2
3
4
5
Zero - Clicked by accident
$25
Clear selection
Culver's (5%)
1
2
3
4
5
Zero - Clicked by accident
$10
Clear selection
Dairy Queen (5%)
1
2
3
4
5
Zero - Clicked by accident
$5
$10
$20
Clear selection
Dick's Fresh Market (5%)
1
2
3
4
5
Zero - Clicked by accident
$25
$50
$100
Clear selection
Fazoli's (7%)
1
2
3
4
5
Zero - Clicked by accident
$25
Clear selection
Fleet Farm (5%)
1
2
3
4
5
Zero - Clicked by accident
$25
$100
Clear selection
Fresh Wok (5%)
1
2
3
4
5
Zero - Clicked by accident
$10
$25
Clear selection
GAP / Banana Republic / Old Navy (9%)
1
2
3
4
5
Zero - Clicked by accident
$25
Clear selection
Hill's Hardware Hank (5%)
1
2
3
4
5
Zero - Clicked by accident
$10
$25
$100
Clear selection
Home Depot (5%)
1
2
3
4
5
Zero - Clicked by accident
$25
Clear selection
HyVee (3%)
1
2
3
4
5
Zero - Clicked by accident
$25
$100
Clear selection
Interstate Building Supply (3%)
iTunes (5%)
1
2
3
4
5
Zero - Clicked by accident
$10
$15
Clear selection
JCPenney (5%)
1
2
3
4
5
Zero - Clicked by accident
$25
$100
Clear selection
Kohls (4%)
1
2
3
4
5
Zero - Clicked by accident
$25
Clear selection
Kwik Trip (5%)
1
2
3
4
5
Zero - Clicked by accident
$10
$25
$50
$100
$200
Clear selection
Land's End (16%)
1
2
3
4
5
Zero - Clicked by accident
$25
Clear selection
Lowe's (4%)
1
2
3
4
5
Zero - Clicked by accident
$25
$500
Clear selection
Macy's (10%)
1
2
3
4
5
Zero - Clicked by accident
$25
Clear selection
Maurice's (7%)
1
2
3
4
5
Zero - Clicked by accident
$20
Clear selection
McDonald's (5%)
1
2
3
4
5
Zero - Clicked by accident
$5
$10
Clear selection
Menards (3%)
1
2
3
4
5
Zero - Clicked by accident
$25