Credit Card Payment form (VISA, MASTERCARD, DISCOVER) AMEX NOT ACCEPTED

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1 Helen Keller PTO Hot Lunch 2nd Installment Dear Keller Families, Thank you in advance for supporting the PTO. Here is the hot lunch order form covering lunch through February 28th. When placing your order, please keep the following in mind: Helen Keller School does not assume any responsibility due to food allergies or other health and diet concerns. Please keep this in mind when ordering. ~ Make your selections carefully since orders cannot be changed. ~ Please complete one order form PER STUDENT. ~ Please make checks payable to Helen Keller PTO, or use credit card form (NO AMEX) ~ All orders must be turned in by Friday, November 8th. ~ In the event of absence, lunch may be picked up during their lunch period, but you must inform the office when calling to report them absent. ~ Extra item only available after first item selected ~ PLEASE NOTE: Due to significant check fees incurred from non sufficient funds, there will be a $25 fee for returned checks and hot lunch orders will not be processed until all "NSF" fees have been remitted. If you have any questions, please contact Angie Jones (773) abaier@comcast.net or Priscilla Kooyenga (708) priscilla.kooyenga@sbcglobal.net Thank you! Credit Card Payment form (VISA, MASTERCARD, DISCOVER) AMEX NOT ACCEPTED Student name: Name on card: Address: Card number: Phone number: Expiration date: Amount: 3 digit code on back: Signature: Due to increased processing fees there is a $1.00 fee for credit cards

2 Name: Room #: Nov. 18 Nov. 22 Dec. 2 Dec. 6 Dec. 9 Dec. 13 Dec. 16 Jan. 6 SALINAS Qty All Beef Hot Dog and Ruffles Potato $3.00 = Qty Extra Hot $1.25 = PANDA EXPRESS Qty Orange Chicken with steamed rice and fortune $3.50 = Qty Vegetable Fried Rice and fortune $2.50 = Qty Chicken Egg Roll and fortune $1.50 = SKILLET HOUSE Qty 2 Chicken Tenders and 9 oz $4.00 = Qty English Muffin with pork sausage $2.75 = Qty 3 $2.75 = NICK'S BBQ Qty Plain Hamburger and Lays Potato $3.00 = GIORDANOS Qty 8oz butter bow tie pasta and $4.00 = Qty 3 pc cheese ravioli with marinara and $3.25 = Qty 3 pc chicken tenders and $2.25 = SALINAS Qty All Beef Hot Dog and Ruffles Potato $3.00 = Qty Extra Hot $1.25 = Page 1 Total:

3 Name: Room #: Jan. 10 Jan. 13 Jan. 17 Jan. 24 Jan. 27 Jan. 31 Feb. 3 Feb. 7 CULVERS Qty 2 Chicken $2.75 = Qty Corn Dog $2.75 = Qty Plain $2.75 = Qty Frozen Vanilla $1.50 = Qty Frozen Chocolate $1.50 = LET'S DO LUNCH Qty 2 pc thick french toast w/2 beef sausage $3.50 = Qty 8 oz. Chicken Noodle soup w/oyster $3.25 = Qty Cheesy $2.50 = Qty Garden salad with ranch $1.75 = SUBWAY Qty 6 " plain ham and cheese, lays potato chips, $4.00 = Qty 6 " plain turkey and cheese, lays potato chips, $4.00 = NICK'S BBQ Qty Plain Hamburger and Lays Potato $3.00 = POP'S Qty 4" Beef $3.75 = Qty 5 pc Mac & Cheese $3.00 = Qty 8 pc mini $3.00 = Qty 1.5 oz bag mini $0.50 = MCDONALDS Qty Plain McDouble $1.75 = Qty Plain $1.75 = Qty 2 oz. bag Famous Amos Chocolate Chip $0.50 = Page 2 Total:

4 Name: Room #: Feb. 10 Feb. 14 Feb. 21 Feb. 24 Feb. 28 SALINAS Qty All Beef Hot Dog and Ruffles Potato $3.00 = Qty Extra Hot $1.25 = NICK'S BBQ Qty Rib Sandwich $3.75 = Qty 8 oz cream of chicken $2.75 = Qty Beef Corn $2.50 = Qty 2 oz fudge stripe $0.50 = WHITE CASTLE Qty 3 plain $2.75 = Qty 3 plain $3.25 = Qty 6 pc chicken $3.00 = Qty 1.8 oz M&M $0.50 WINSTON'S MARKET Qty 2 Chicken tenders with potato wedges and a $4.25 = Qty 4 oz turkey with 4 oz mashed $4.25 = Qty 8 oz Macaroni and Cheese $2.50 = Page 3 Total: Amount Due to Keller PTO:

5 Please keep this page as a record of your order. DATE VENDOR SELECTION Nov. 18 Nov. 22 Dec. 2 Dec. 6 Dec. 9 Dec. 13 Dec. 16 Jan. 6 Jan. 10 Jan. 13 Jan. 17 Jan. 24 Jan. 27 Jan. 31 Feb. 3 Feb. 7 Feb. 10 Feb. 14 Feb. 21 Feb. 24 Feb. 28 SALINA'S PANDA EXPRESS SKILLET HOUSE NICK'S GIORDANO'S SALINA'S CULVER'S LET'S DO LUNCH SUBWAY NICK'S POP'S MCDONALDS SALINA'S NICK'S WHITE CASTLE WINSTON'S

6 Nutritional Information If you are interested in obtaining further information for items offered through the Hot Lunch Program, please contact the following vendors by calling the number listed or visiting their websites: Let's Do Lunch White Castle Salina's Pop's Dominos Giordano's Skillet House McDonald's Culver's Subway Panda Express Nick's BBQ