St. Robert "SCRIP" Order Form

Instructions:

  • Fill out all appropriate fields.
  • All fields in 'Red' are required fields and must be completed.
  • After all requests have been entered, either select the 'SUBMIT Scrip Order' button at the bottom of this form (the fields entered will be E-Mailed to the St. Robert's Scrip Coordinator). Also, please be sure to have your payment (Check or Cash) ready at time of scrip pick up.
    - - OR - -
    Print out the completed form and send it to the Rectory. Please enclose payment with your order form.
  • Scrip orders will be available on Wednesday afternoons for pickup at the Rectory or delivery via school & your child.
  • For pickup at Rectory: payment can be made at time of order, or time of pickup.
  • For delivery via the School through your child: payment must be made with the order form.


*Purchaser's Name:

*Telephone #: *E-Mail Address:

Scrip Delivery Method

I will pick up the Scrip at the Rectory.

--- OR ---

Deliver Scrip to my child through the school.

Scrip delivery request and release.

I request, that with this scrip order, the scrip purchased by me, be delivered to me by my child as shown below. I understand that this delivery arrangement is for my convenience. I agree St. Robert's obligation ends once the scrip is delivered to my child. As such, I agree to release and hold St. Robert's harmless for any loss once my scrip is delivered to my child.

*Child's Name: .. *Child's Grade:

Go to:

Grocery - Gas and Auto - Travel Section

Retail Stores - Restaurants - Drug Stores

Entertainment

GROCERY
Increments
Store Total $

Lunardi's
$10

Lunardi's
$25

Mollie Stones
$10

Mollie Stones
$20

Safeway / Pak' N Save
$25

Safeway / Pak' N Save
$100

Smart and Final
$25

Smart and Final
$50

Smart and Final
$100

GAS AND AUTO
Increments
Store Total $

Arco
$50

Chevron
$50

Chevron
$250

Exxon (Mobil)
$50

Exxon (Mobil)
$250

Shell Prepaid Card
$25

Shell
$50

Shell
$100

Kragen Auto Parts
$25

TRAVEL SECTION
Increments
Store Total $

Avis Car Rental
$50

Budget Car Rental
$50

Comfort Inn
$25

Comfort Inn
$100

Marriott Hotels
$50

Marriott Hotels
$100

Marriott Hotels
$500

Disney Gift Card
$25

Disney Gift Card
$100

Disney Gift Card
$1,000

RETAIL STORES
Increments
Store Total $

Bath & Body Works
$10

Bath & Body Works
$25

Barnes & Noble, B. Dalton
$10

Barnes & Noble, B. Dalton
$25

Bed, Bath & Beyond
$25

Best Buy
$25

Best Buy
$100

Best Buy
$250

Big 5 Sporting Goods
$25

Borders / Waldenbooks
$10

Borders / Waldenbooks
$25

Build-A-Bear Workshop
$25

Children's Place
$25

Circuit City - purchase only
$50

Circuit City - purchase only
$100

Claire's
$10

Dream Dinners
$75

EB Games/Game Stop
$25

GNC
$25

Gymboree
$25

Home Depo
$25

Home Depo
$100

Home Depo
$500

J.C. Penny
* Pay on account
$25

J.C. Penny
* Pay on account
$100

Joann Fabrics
$20

Kohl's Department Store
$25

Kohl's Department Store
$100

Linens 'n Things
$25

Lowe's Home Improvement
$25

Lowe's Home Improvement
$100

Lowe's Home Improvement
$500

Lowe's Home Improvement
$1,000

Macy's
$25

Macy's
$100

Marshalls / T.J. Max
$25

Office Depot
$25

Old Navy, Banana Republic, GAP
$25

Payless Shoe Source
$20

Pier 1 Imports
$25

Ross Dress for Less
$25

Sears / Orchard Supply Hardware
(Purchase only)
$25

Sears / Orchard Supply Hardware
(Purchase only)
$100

Sears / Orchard Supply Hardware
(Purchase only)
$250

Sportmart / Gart / Sports Authority
$25

Staples
$25

Toy's R Us / Babies-R-Us
$20

Ulta Salon
$25

Wal-Mart
$25

Wal-Mart
$100

Wal-Mart
$250

William Sonoma, Pottery Barn,
Crate & Barrel, Hold Everything
$25

William Sonoma, Pottery Barn,
Crate & Barrel, Hold Everything
$100

RESTAURANTS
Increments
Store Total $

Baskin Robbins
$2

Buca di Beppo
$25

Burger King
$10

Carl's Jr.
$10

Cheescake Factory
$25

Chevy's
$25

Chili's / Macaroni Grill
$25

Chuck E. Cheese
$10

Darden Restaurants - Olive
Garden, Red Lobster
$25

Jamba Juice
$10

Kentucky Fried Chicken
$5

Marie Callender's
$25

Outback Steakhouse
$25

Peets Coffee
$20

Rainforest Cafe
$25

Red Robin
$10

Starbucks
$10

Starbucks
$25

TGIF Fridays
$25

Wendy's
$10

DRUG STORES
Increments
Store Total $

Long's Drugs
$25

Long's Drugs
$100

Walgreen's
$20

Walgreen's
$100

ENTERTAINMENT
Increments
Store Total $

i-Tunes
$25
Enter Total Dollar amount ordered:

If there are other stores you would like Scrip from, let us know: 

                        Revised: June 4, 2008 - © grd

Submitting this form will result in an E-Mail to Christine Peterson, our Scrip Coordinator with your request(s).

For a greater selection of stores, go to: ShopWithScrip.com

Saint Robert's School ID# / Enrollment Code: DA81751D9953
 (this code is case sensitive and must be entered exactly as shown)
(If you don't have a 'Member's Login', you will have to create one.)