Release Form for Laurelhurst Scrip Program Internet copy - Print out and fill in, then return to office. Laurelhurst Elementary School PTA 840 NE 41st Avenue Portland, Oregon 97232 PLEASE COMPLETE ONE PART IN INK

I understand scrip is like cash and agree that the Laurelhurst Elementary School PTA will have no liability for lost or stolen scrip certificates after I receive the certificates. I hereby release and agree to hold harmless the Laurelhurst Elementary School PTA (including its employees, officers, volunteers and agents) for lost or stolen scrip certificates. This Scrip Release Form is valid for the school year 2000 unless the Laurelhurst Elementary School PTA receives written notification from me that is it no longer valid. Parent signature: _________________________________ Date: __________________ Parent name: ____________________________________ Phone: ________________ Please print legibly) Student name: ___________________________________ (Please print legibly) Selected scrip (Fred Meyer, Safeway, Natures, QFC, McDonalds, Burger King, Toys "R" Us, and Hollywood Video) can be purchased at school during normal school hours. Orders for any merchant on the order form can be placed anytime during school hours. Orders placed by 9AM Tuesdays will be ready for pick-up after 3PM on Thursdays. Orders can be dropped off in the office (see Barbara). Payment must be included with order. Make your checks payable to Laurelhurst PTA. If you have any questions please call Vickie Wilkinson at (503)-282-7040. This Scrip Release Form is valid for the school year 1999-2000 unless the Laurelhurst PTA receives written notification from me that is it no longer valid. Parent signature: ______________________________ Date: _________________ Parent name: _________________________________ Phone: ________________ (Please print legibly)

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