2023-2024 SJCA SCRIP Enrollment & Waiver Form

2023 - 2024

SJCA SCRIP

Enrollment & Waiver Form

Accrual Period 05/01/2023 - 04/30/2024

Note: A new form is required each school year.
Parent Name*

PrefixNameLast NameSuffix
Student's Last Name *
Student's Last Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Daytime Phone Number*
E-mail*
example@example.com
† I understand that 50% of the rebates generated from my orders will be credited to St. Joseph Catholic Academy Parent Association, and 50% will be allocated as indicated below as my family designation (choose ONE of the following):
1. My Family's SJCA Tuition Account
2. SJCA Parent Association
3. SJCA Anonymous Tuition Donor
4. My Family's Parish
5. Other Family's SJCA Tuition Account
Choose one option:*

1. My Tuition Account2. SJCA Parent Assn.3. Anonymous Tuition Donor4. Parish (see below)5. Other Tuition Account (see below)
If you selected option 4 or 5 above, provide Parish or Family Name
Parish or Family Name
- I understand that if my family-designated portion of the total rebate is less than $10.00, the rebate will be applied to the St. Joseph Catholic Academy Parent Association Account.
- By participating in the SCRIP Program, I agree not to hold St. Joseph Catholic Academy Parent responsible for lost, stolen or expired certificates. (See the SJCA Website for full SCRIP program details at www.sjcawi.org.)
Please indicate below if
- the student / ward will be responsible for delivering the SCRIP folder home every week, and parent / guardian will complete the Waiver Form below;
  OR,
- a parent / guardian will be picking up the SCRIP folder in the Main Office of the Upper or Lower Campus on Fridays before the end of the day. (A Waiver Form is unnecessary if student will not be transporting SCRIP cards)
*

Student DeliveryParent Pickup
By typing my name in the box below, I am agreeing with the above SCRIP program policies.
Parent Signature
Please type full name
PERMISSION FOR CHILD / WARD DELIVERY OF SCRIP & WAIVER OF CLAIM FORM

This agreement is effective for the 2023-2024 school year.
Please send my SCRIP folder home with my student (see below).
Student / Ward responsible to deliver SCRIP home.
Provide all student names applicable.
Student's Grade
Lower Campus Student's Teacher
SCRIP folders will be sent to the LC classroom to be sent home.
- I give permission to St. Joseph Catholic Academy (SJCA) to deliver SCRIP, which I have ordered from the SJCA SCRIP program, to my student/ward named above. (More than one student can be named).
- I understand that my student / ward will be responsible for the safe transport of the SCRIP from SJCA to my home, and certify that I have discussed the responsibilities associated with the transport of the SCRIP with my student / ward.
- I further understand that I have the option of personally picking up my SCRIP orders from SJCA rather than having my student / ward transport it.
- I agree that once SJCA delivers the SCRIP to my student / ward that SJCA / St. Joseph Catholic Academy Parent Association SCRIP program is not responsible for any SCRIP which is lost, stolen, or misplaced.
- I hereby waive any right of recovery that I may have against SJCA / St. Joseph Catholic Academy Parent Association SCRIP program for SCRIP which is lost, stolen, or misplaced after it is given to my student / ward.
By typing my name in the box below, I am agreeing with the above Waiver of Claim form required by the Archdiocese of Milwaukee.
Parent Signature
Please type full name
Should be Empty:

PERMISSION FOR CHILD / WARD DELIVERY OF SCRIP & WAIVER OF CLAIM FORM