Scrip Order Form
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C.T. DOUGLAS ELEMENTARY SCHOOL SCRIP ORDER FORM
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All orders are due on FRIDAY, June 8. Orders will be delivered on Monday, June 18.
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PLEASE LOOK ONLINE FOR ADDITIONAL RETAILERS
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You can add a retailer in any empty row
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Please fill out form completely - Orders due FRIDAY, June 8
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Your Name
Child's Teacher
Phone #
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Child's Name
E-Mail
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APPARELSPECIALTY RETAILERENTERTAINMENT
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Product%QtyTotal
Product
%QtyTotal
Product
%QtyTotal
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Aerie $2510.0%$
Amazon.com $25 (paper)
3.00%$AMC Theatres $1010.0%$
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Aeropostale $25
10.0%$
Amazon.com $100 (paper)
3.00%$$
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American Eagle $25
10.0%$
Barnes & Noble $10
9.0%$
Best Buy $25
4.0%$
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Athleta $2514.0%$
Barnes & Noble $25
9.0%$
Game Stop $25
3.0%$
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Children's Place $25
12.0%$
Build-A Bear $25
8.0%$
iTunes $15
5.00%$
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Express $2512.00%$
Claire's $10
9.0%$
Regal Ent. Group $25
8.0%$
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Gap/BR/Old Navy/Athleta $25
14.0%$
Disney $25
3.0%$
RegalSingle Admit $10
10.0%$
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Gymboree $25
13.0%$
Groupon $25
7.0%$
Shutterfly $25
9.0%$
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J. Crew $2513.0%$
Hallmark $25
4.0%$
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Land's End $25
16.0%$OfficeMax $1005.0%$
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Overstock.com $25
8.0%$
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L.L.Bean $25
16.00%$
PetSmart $25
5.0%$
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Nike $2512.0%$
Sephora $20
4.0%$
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Talbots $2513.0%$
Staples $25
5.0%$
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Super Cuts $25
8.0%$
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Zappos $25
8.0%$HEALTH & BEAUTY
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DEPARTMENT STORES
Product
%QtyTotal
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Product%QtyTotal
Bath&Body Works $25
13.0%$
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Bed Bath & Beyond $25
8.0%$
CVS $25
10.0%$
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Bloomingdale's $25
12.0%$
GNC $25
8.0%$
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Brooks Brothers $25
16.0%$
Walgreens $25
5.0%$
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Christmas Tree Shop
8.0%$HOME DÉCOR
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Dress Barn $25
8.0%$
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Product
%QtyTotal
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Footlocker $25
8.0%$
Ace Hardware $25
4.0%$DISCOUNT STORES
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JCPenney $25
5.0%$
Container Store $25
9.0%$
Product
%QtyTotal
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Lowe's $25 Gift Card
4.0%$
Kmart $25
4.0%$
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Kohl's $254.0%$
Pier 1 Imports $25
9.0%$Payless Shoes $2013.0%$
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Lord & Taylor $25
8.0%$
Pottery Barn/Will. Son.$25
8.0%$
Sam's Club $25
2.5%$
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Macy's $2510.0%$
WalMart $25
2.50%$
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Marshalls $25
7.0%$
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Nordstroms6.0%$SPORTING GOODS
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Sears $25 4.0%$
Product
%QtyTotal
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T.J.Maxx $25
7.0%$
Bass Pro Shops $25
9%$
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Target $252.5%$
Dick's Spor. Good $25
8.0%$
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Finish Line $25
10.0%$
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REI $25
8.0%$
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TRAVEL
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Product
%QtyTotal
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Hotels.com
6.0%$SERVICE
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Hilton8.0%$
Product
%QtyTotal
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ARTS & CRAFTS
Auto Zone $25
8.0%$
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Product%QtyTotal
Exxon / Mobil $50
1.5%$
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Jo Ann Fabrics $25
6.0%$
Gulf $25
1.5%$
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AC Moore 5.0%$
Shell $25
2.5%$
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Michaels $25
4.0%$
Sunoco $50
1.5%$
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DINING-CASUAL
DINING-ON THE GO
GROCERY
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Product%QtyTotal
Product
%QtyTotal
Product
%QtyTotal
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99 Restaurant & Pub $25
13.0%$
Shaws $25
4.0%$
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Applebee's $25
8.0%$
Bruegger's Bagel $10
7%$
Shaws $100
5.0%$
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Bertucci's $25
10.0%$
Burger King $10
4%$
Stop & Shop $50
4.0%$
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Domino's Pizza $10
8%$
Whole Foods $100
3.0%$
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Boston Market $10
12.0%$
Dunkin Donuts $10
3%$
Stop & Shop $100
4.0%$
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California Pizza Kitchen $10
6.0%$
Panera Bread $10
8%$
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Cheesecake Factory $25
5.0%$
Papa Gino's/D'Angelo $10
10%$
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On The Border $25
14.0%$
Pizza Hut $10
8%$
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Chuck E Cheese $10
8.0%$
Starbucks $10
7%$
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Cold Stone Creamery $10
8.0%$
Starbucks $25
7%$
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Cracker Barrel $10
9.0%$
Subway $10
6%$
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Wendy's $10
4%$
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Landry's Seafood $25
9.0%$
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Legal Sea Foods $25
13.0%$
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Olive Garden/Red Lobster $25
9.0%$
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Outback $25
8.0%$
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P.F. Changs $25
8.00%$
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TGI Fridays $25
9.0%$
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Ruby Tuesday's $25
8.0%$
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Release Form
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By signing below, I authorize C.T.Douglas Elementary School PTO to release my Scrip to
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_________________________________ for delivery to me. My signature also holds the
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(Name of Student)
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For all questions please contact:
PTO and school harmless for loss once SCRIP is delivered.
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Stacey Smith - sbtsmith@verizon.net
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______________________________ ____________
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(Signature of Parent/Guardian)
(Date)
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Total # of Certificates
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Check #
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Total Amount $
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