Fox Valley Lutheran High School (“FVL”) sponsors a SCRIP program which allows the purchase of gift or shopping cards from various merchants and generates rebates from those merchants. The rebates can be used as a credit to your high school tuition, a donation to the school, or cash back. Please indicate your choice concerning the use of your rebate. The rebates that you generate will be distributed annually in June. The SCRIP year runs from June 1 through May 31.

Annual statements will be provided to Parent/Guardian in late June of each year. Charitable contributions will be acknowledged pursuant to sections 170(f)(8) and 170(f)(17) of the Internal Revenue Code.

SCRIP Purchaser's Information

First Name (names if married) *

Last Name *

Address *

City *

State *

Zip Code *

Do you already have a ShopWithScrip account from another Scrip program and want to use the same log in. If your email is already used in another program, FVL scrip will not be able to fully set up your account and you will be notified by email of your options. *

Yes

Email Address *

Primary Phone Number *

Primary Phone is . . . *

Home

Mobile

Work

Secondary Phone Number

Secondary Phone is . . .

Home

Mobile

Work

Please select one of the following options for your portion of the rebate *

Use my portion of the rebate to credit TUITION account for specific students (list below)

Use my portion of the rebate as a gift to FVL Financial Aid (potentially tax deductible)

Use my portion of the rebate as a gift to the "Let the Children Come" annual mortgage payment

Use my portion of the rebate as a gift to the "Angel Fund" which helps pay tuition for seniors whose parents have financial difficulties

Pay my portion of the rebate as CASH back to me (in late June)

If you do not change your SCRIP designation and you have a credit but no tuition bill, your designation will default to cash back.

Designated Student(s) to receive SCRIP credit

Please input students in order of graduation, listing the oldest student first. If you wish to split your credits between two or more students/families at the same time, please explain in the comment section at the end of this form.

Student 1 First Name *

Student 1 Last Name *

Student 1 Parent's Full Name (if you are NOT the parent)

Student 1 Grad. Year *

If NOT the parent, please list your relationship to the student in the comment box at the end of this form.

Student 2 First Name

Student 2 Last Name

Student 2 Parent's Full Name (if you are NOT the parent)

Student 2 Grad. Year

If NOT the parent, please list your relationship to the student in the comment box at the end of this form.

Student 3 First Name

Student 3 Last Name

Student 3 Parent's Full Name (if you are NOT the parent)

Student 3 Grad. Year

If NOT the parent, please list your relationship to the student in the comment box at the end of this form.

Student 4 First Name

Student 4 Last Name

Student 4 Parent's Full Name (if you are NOT the parent)

Student 4 Grad. Year

If NOT the parent, please list your relationship to the student in the comment box at the end of this form.

SCRIP Details and Required Signature

You agree to indemnify FVL against any loss incurred in connection with insufficient funds in your account to cover checks or ACH transfers you issue to pay for your SCRIP. FVL makes no representations or warranties of any kind with respect to SCRIP. This agreement continues unless replaced by another, and can be amended or terminated by either party upon 60 days’ advance notice to the other.

You agree that you are responsible for any NSF/bank fees resulting from paying by check.

Please sign and date below to indicate your acknowledgment of this agreement.

Signature *

Today's Date * +

Comments/questions here!

If you have trouble with this online form, please email scrip@fvlhs.org for help.

Someone from the SCRIP Office
will be in contact with you to confirm your information.

Thank you for registering with the FVL SCRIP Program!