Scrip Order Form

Name:	Order Date:

Phone:	Email:

To purchase a gift card, please complete this Scrip Order Form in  easy steps and return it with your payment to the School Office by 10am on Monday, in your School Family Envelope, or at the Scrip Cart after mass.

Scrip Selection:	Office Use
Name of Store/Retailer	Denom.	Qty.	Total	ScripToGo	On Order
Example: In-N-Out Burger	$10	2	$20
[Right-click in the cell to the right and select “Update Field.”] Total:	$ 0.00

The Rebate(s) generated from your Scrip purchase will be split 50/50 with you as designated in your CTK Scrip Program Agreement. Need to complete/sign a CTK Scrip Program Agreement? Go to ctkscrip.weebly.com.

Please be advised, without a signed Scrip Program Agreement, Scrip Rebates earned by CTK School Families will be allocated as

Tuition Credits and Scrip Rebates earned by Non-CTK School Families will be allocated as Charitable Contributions to CTK School.

Paying By: Cash (Receipt No. _________) Check (No. ) Scrip Purchase Order Pick Up: ScripToGo At Scrip Cart after school Send Scrip home with my oldest child: (Purchased in Thursday, before/after school Person at Scrip Friday, or after most masses Student: Grd: Cart) on Sunday for Scrip Orders placed by Monday at 10am Signature: (Required for Release – Type Name for Digital Signature)

You agree to repay CTK any loss incurred in connection with insufficient funds used to pay for Scrip.

Please sign below to indicate your acknowledgement of this agreement and that your Scrip was received:

 ScripToGo Completed Picked up by: _____________________________________	 On Order Completed Picked up by: _____________________________________ Date: ____________________________________________

Christ the King cannot be responsible for lost or stolen gift cards. Purchased gift cards should be treated like cash.

Should you encounter any problem using your gift cards purchased through the CTK Scrip Program, please contact Shelley Conner at sconner@ctk-catholicschool.org.

Christ the King School neither endorses nor promotes the Scrip Retailers.	Questions: scrip@ctk-catholicschool.org