Student Information (account requesting refund from):
Last Name:
First Name:
School: East ElementaryPendleton ElementaryMaple Ridge ElementaryPendleton Heights Middle SchoolPendleton Heights High School
Reason for refund:
Left School District Graduated Other Specify:
Anticipated amount of refund: $
Please indicate how you would like to receive refund from the following 3 options:
Paper Check
Parent/Legal Guardian to make check payable to: First / Last Name Address City State Zip
Transfer to another student's account
Student First/Last Name Grade School East ElementaryPendleton ElementaryMaple Ridge ElementaryPendleton Heights Middle SchoolPendleton Heights High School
Donate funds to SMCSC Donation Account This fund is used to provide extra help to students whose parents struggle to keep cafeteria accounts current.
Person completing this form:
First/Last Name: Email Address: