Enrollment and Waiver Form

Great Bridge Band Parent Association Scrip Program

Program rules and guidelines

1) All certificate orders must be accompanied by a check or money order made payable to GBBPA. Please do not send cash. Scrip certificate payments are not tax deductible because you receive dollar for dollar value.

2) If your check is returned because of non-sufficient funds (NSF), you will be charged a $20 fee payable to GBBPA. After two NSF checks are tendered on your account, your scrip ordering privileges will be limited to money order only.

3) Upon request, GBBPA will provide a summary of each participating family’s purchases.

4) Scrip certificates are purchased on your behalf, and are not returnable.

5) When you pick up your scrip certificates, open your order and verify its accuracy. Your signature on the Order Pickup List indicates you have received your order in its entirety. This will be verified at the time of pick up. You or your designee will be required to have a photo ID. In the unlikely event you should find a discrepancy in your scrip order, please contact the GBBPA Scrip Program coordinator within 7 days.

6) Scrip certificates are the same as cash, and should be handled accordingly. The GBBPA will not be responsible for certificates that are lost, stolen or misplaced while in your possession.

7) You must sign a WAIVER OF RESPONSIBILITY form (below) before certificates will be released with your child or another party. These forms will be kept on file, and GBBPA accepts no responsibility for certificates delivered in this manner. Certificates will not be released to your child at school, pick up will be available.

WAIVER OF RESPONSIBILITY

I give permission for the individuals listed below to pick up my scrip orders for me.

The signature of that person(s) indicates delivery of certificates to myself and

releases the GBBPA and Great Lakes Scrip from any responsibility with regard to loss or damage.

I understand that the persons I designate below will be required to show picture

identification and verify the contents and completeness of my order. They will be

asked to sign that they have made the verification. If there is a discrepancy, there

will be a form completed and the Scrip coordinators will be informed and the

discrepancy handled within 7 days.

First Name:_________________________________________________ Last Name____________________________________

Street Address______________________________________________________________________________________________

City__________________________________________________________ State________ Zip_________________

Phone__________________________________ cell phone ____________________email____________________________________

Persons with permission to pick up my Scrip Order:

1._________________________________________________________

2._________________________________________________________

3__________________________________________________________

I have read and understand the policies and guidelines listed above, and I agree to abide by these policies.

____________________________________________________________________________

Signature and Date

Office only:

Enrollment form completed_______

Envelope completed _______