OLPH SCRIP/TRIP Program Enrollment Form Please return this form with your 1st order ONLY. Please Print First Name
Last Name
Address
City, State, Zip
Apply my credit to the following: Choose ONLY one.
If you have chosen either OLPH or NDHS Tuition, please indicate the first and last name of oldest child at the school you have selected and the name of their parent/guardian.
OLPH Tuition* NDHS Tuition**
Student Name:_______________________
Home & School OLPH Tuition Assistance Fund
Parent/Guardian Name:_______________________________
Email Address 1
Email Address 2
Cell phone
OLPH Grade and/or homeroom teacher.
Home Phone
I do not have internet access. I cannot order online Check if “YES�
*OLPH and NDHS Tuition credit is for the 2010-2011 school year. **OLPH 8th grade students going to NDHS should choose NDHS tuition.
I have read and understand the OLPH Scrip Program Rules and Guidelines outlined in this packet and I agree to abide by these policies. __________________________________________________________________ _
Signature
Date
8