1.	First Name:*

2.	Last Name:*

3.	E-mail Address:*

4.	Home Phone:*

5.	Cell Phone:*

6.	Tell us where to apply your 50% earnings:*
	I am a SCBCS parent - apply credit to my tuition Apply to SCBCS Tuition Assistance Program Apply to school operating expenses I am a staff member - apply credit to my classroom supply account Apply to BMHS Tuition Savings Account Apply my portion of earnings as a tax deductible donation Apply tuition credit to another family - enter family name below

7.	If you have elected SCBCS tuition credit, please elect the month you would like the tuition credit applied. Annual or semi-annual tuition payment plans will automatically receive a credit in August.
	-- None --May August

8.	Do you have a child enrolled at St. Charles School?*
	Yes No

9.	I authorize the following ADULTS to pickup my scip order. I will not hold St. Charles Catholic School/Church accountable for any lost, stolen or damaged certificates/cards once the order has left the school. (enter up to 4 names in the text box provided.)
	Name 1:   Name 2:   Name 3:   Name 4: Names