Special Lunch - Culver's

This order form is for Special Lunch on

October 20th at Meridian and Tripp

October 27th at Pritchett and AJHS

Culver's will be providing your choice of options - see below.

Each option comes with chips & custard

Item Description Price Qty

Special Lunch - Culver's - October 2026 $10.00 Options: Butter Burger Single
ButterBurger w/ Cheese Single
Gluten Free Butter Burger Single
2 pc Chicken Tender
Grilled Cheese
Garden Salad (no meat - veggie option)

Butter Burger Single #1	Student First Name Student Last Name School (reset) Pritchett-October 27 Tripp-October 20 Meridian-October 20 Aptakisic-October 27 Homeroom/Advisory Teacher* Custard flavor (reset) Vanilla Chocolate None Does your student have a dairy allergy? (reset) Yes No Does your student have an egg allergy? (reset) Yes No	copy
Butter Burger Single #2	Student First Name Student Last Name School (reset) Pritchett-October 27 Tripp-October 20 Meridian-October 20 Aptakisic-October 27 Homeroom/Advisory Teacher* Custard flavor (reset) Vanilla Chocolate None Does your student have a dairy allergy? (reset) Yes No Does your student have an egg allergy? (reset) Yes No
Butter Burger Single #3	Student First Name Student Last Name School (reset) Pritchett-October 27 Tripp-October 20 Meridian-October 20 Aptakisic-October 27 Homeroom/Advisory Teacher* Custard flavor (reset) Vanilla Chocolate None Does your student have a dairy allergy? (reset) Yes No Does your student have an egg allergy? (reset) Yes No
Butter Burger Single #4	Student First Name Student Last Name School (reset) Pritchett-October 27 Tripp-October 20 Meridian-October 20 Aptakisic-October 27 Homeroom/Advisory Teacher* Custard flavor (reset) Vanilla Chocolate None Does your student have a dairy allergy? (reset) Yes No Does your student have an egg allergy? (reset) Yes No
Butter Burger Single #5	Student First Name Student Last Name School (reset) Pritchett-October 27 Tripp-October 20 Meridian-October 20 Aptakisic-October 27 Homeroom/Advisory Teacher* Custard flavor (reset) Vanilla Chocolate None Does your student have a dairy allergy? (reset) Yes No Does your student have an egg allergy? (reset) Yes No
Butter Burger Single #6	Student First Name Student Last Name School (reset) Pritchett-October 27 Tripp-October 20 Meridian-October 20 Aptakisic-October 27 Homeroom/Advisory Teacher* Custard flavor (reset) Vanilla Chocolate None Does your student have a dairy allergy? (reset) Yes No Does your student have an egg allergy? (reset) Yes No
Butter Burger Single #7	Student First Name Student Last Name School (reset) Pritchett-October 27 Tripp-October 20 Meridian-October 20 Aptakisic-October 27 Homeroom/Advisory Teacher* Custard flavor (reset) Vanilla Chocolate None Does your student have a dairy allergy? (reset) Yes No Does your student have an egg allergy? (reset) Yes No
Butter Burger Single #8	Student First Name Student Last Name School (reset) Pritchett-October 27 Tripp-October 20 Meridian-October 20 Aptakisic-October 27 Homeroom/Advisory Teacher* Custard flavor (reset) Vanilla Chocolate None Does your student have a dairy allergy? (reset) Yes No Does your student have an egg allergy? (reset) Yes No
Butter Burger Single #9	Student First Name Student Last Name School (reset) Pritchett-October 27 Tripp-October 20 Meridian-October 20 Aptakisic-October 27 Homeroom/Advisory Teacher* Custard flavor (reset) Vanilla Chocolate None Does your student have a dairy allergy? (reset) Yes No Does your student have an egg allergy? (reset) Yes No
ButterBurger w/ Cheese Single #1	Student First Name Student Last Name School (reset) Pritchett-October 27 Tripp-October 20 Meridian-October 20 Aptakisic-October 27 Homeroom/Advisory Teacher* Custard flavor (reset) Vanilla Chocolate None Does your student have a dairy allergy? (reset) Yes No Does your student have an egg allergy? (reset) Yes No	copy
ButterBurger w/ Cheese Single #2	Student First Name Student Last Name School (reset) Pritchett-October 27 Tripp-October 20 Meridian-October 20 Aptakisic-October 27 Homeroom/Advisory Teacher* Custard flavor (reset) Vanilla Chocolate None Does your student have a dairy allergy? (reset) Yes No Does your student have an egg allergy? (reset) Yes No
ButterBurger w/ Cheese Single #3	Student First Name Student Last Name School (reset) Pritchett-October 27 Tripp-October 20 Meridian-October 20 Aptakisic-October 27 Homeroom/Advisory Teacher* Custard flavor (reset) Vanilla Chocolate None Does your student have a dairy allergy? (reset) Yes No Does your student have an egg allergy? (reset) Yes No
ButterBurger w/ Cheese Single #4	Student First Name Student Last Name School (reset) Pritchett-October 27 Tripp-October 20 Meridian-October 20 Aptakisic-October 27 Homeroom/Advisory Teacher* Custard flavor (reset) Vanilla Chocolate None Does your student have a dairy allergy? (reset) Yes No Does your student have an egg allergy? (reset) Yes No
ButterBurger w/ Cheese Single #5	Student First Name Student Last Name School (reset) Pritchett-October 27 Tripp-October 20 Meridian-October 20 Aptakisic-October 27 Homeroom/Advisory Teacher* Custard flavor (reset) Vanilla Chocolate None Does your student have a dairy allergy? (reset) Yes No Does your student have an egg allergy? (reset) Yes No
ButterBurger w/ Cheese Single #6	Student First Name Student Last Name School (reset) Pritchett-October 27 Tripp-October 20 Meridian-October 20 Aptakisic-October 27 Homeroom/Advisory Teacher* Custard flavor (reset) Vanilla Chocolate None Does your student have a dairy allergy? (reset) Yes No Does your student have an egg allergy? (reset) Yes No
ButterBurger w/ Cheese Single #7	Student First Name Student Last Name School (reset) Pritchett-October 27 Tripp-October 20 Meridian-October 20 Aptakisic-October 27 Homeroom/Advisory Teacher* Custard flavor (reset) Vanilla Chocolate None Does your student have a dairy allergy? (reset) Yes No Does your student have an egg allergy? (reset) Yes No
ButterBurger w/ Cheese Single #8	Student First Name Student Last Name School (reset) Pritchett-October 27 Tripp-October 20 Meridian-October 20 Aptakisic-October 27 Homeroom/Advisory Teacher* Custard flavor (reset) Vanilla Chocolate None Does your student have a dairy allergy? (reset) Yes No Does your student have an egg allergy? (reset) Yes No
ButterBurger w/ Cheese Single #9	Student First Name Student Last Name School (reset) Pritchett-October 27 Tripp-October 20 Meridian-October 20 Aptakisic-October 27 Homeroom/Advisory Teacher* Custard flavor (reset) Vanilla Chocolate None Does your student have a dairy allergy? (reset) Yes No Does your student have an egg allergy? (reset) Yes No
Gluten Free Butter Burger Single #1	Student First Name Student Last Name School (reset) Pritchett-October 27 Tripp-October 20 Meridian-October 20 Aptakisic-October 27 Homeroom/Advisory Teacher* Custard flavor (reset) Vanilla Chocolate None Does your student have a dairy allergy? (reset) Yes No Does your student have an egg allergy? (reset) Yes No	copy
Gluten Free Butter Burger Single #2	Student First Name Student Last Name School (reset) Pritchett-October 27 Tripp-October 20 Meridian-October 20 Aptakisic-October 27 Homeroom/Advisory Teacher* Custard flavor (reset) Vanilla Chocolate None Does your student have a dairy allergy? (reset) Yes No Does your student have an egg allergy? (reset) Yes No
Gluten Free Butter Burger Single #3	Student First Name Student Last Name School (reset) Pritchett-October 27 Tripp-October 20 Meridian-October 20 Aptakisic-October 27 Homeroom/Advisory Teacher* Custard flavor (reset) Vanilla Chocolate None Does your student have a dairy allergy? (reset) Yes No Does your student have an egg allergy? (reset) Yes No
Gluten Free Butter Burger Single #4	Student First Name Student Last Name School (reset) Pritchett-October 27 Tripp-October 20 Meridian-October 20 Aptakisic-October 27 Homeroom/Advisory Teacher* Custard flavor (reset) Vanilla Chocolate None Does your student have a dairy allergy? (reset) Yes No Does your student have an egg allergy? (reset) Yes No
Gluten Free Butter Burger Single #5	Student First Name Student Last Name School (reset) Pritchett-October 27 Tripp-October 20 Meridian-October 20 Aptakisic-October 27 Homeroom/Advisory Teacher* Custard flavor (reset) Vanilla Chocolate None Does your student have a dairy allergy? (reset) Yes No Does your student have an egg allergy? (reset) Yes No
Gluten Free Butter Burger Single #6	Student First Name Student Last Name School (reset) Pritchett-October 27 Tripp-October 20 Meridian-October 20 Aptakisic-October 27 Homeroom/Advisory Teacher* Custard flavor (reset) Vanilla Chocolate None Does your student have a dairy allergy? (reset) Yes No Does your student have an egg allergy? (reset) Yes No
Gluten Free Butter Burger Single #7	Student First Name Student Last Name School (reset) Pritchett-October 27 Tripp-October 20 Meridian-October 20 Aptakisic-October 27 Homeroom/Advisory Teacher* Custard flavor (reset) Vanilla Chocolate None Does your student have a dairy allergy? (reset) Yes No Does your student have an egg allergy? (reset) Yes No
Gluten Free Butter Burger Single #8	Student First Name Student Last Name School (reset) Pritchett-October 27 Tripp-October 20 Meridian-October 20 Aptakisic-October 27 Homeroom/Advisory Teacher* Custard flavor (reset) Vanilla Chocolate None Does your student have a dairy allergy? (reset) Yes No Does your student have an egg allergy? (reset) Yes No
Gluten Free Butter Burger Single #9	Student First Name Student Last Name School (reset) Pritchett-October 27 Tripp-October 20 Meridian-October 20 Aptakisic-October 27 Homeroom/Advisory Teacher* Custard flavor (reset) Vanilla Chocolate None Does your student have a dairy allergy? (reset) Yes No Does your student have an egg allergy? (reset) Yes No
2 pc Chicken Tender #1	Student First Name Student Last Name School (reset) Pritchett-October 27 Tripp-October 20 Meridian-October 20 Aptakisic-October 27 Homeroom/Advisory Teacher* Custard flavor (reset) Vanilla Chocolate None Does your student have a dairy allergy? (reset) Yes No Does your student have an egg allergy? (reset) Yes No	copy
2 pc Chicken Tender #2	Student First Name Student Last Name School (reset) Pritchett-October 27 Tripp-October 20 Meridian-October 20 Aptakisic-October 27 Homeroom/Advisory Teacher* Custard flavor (reset) Vanilla Chocolate None Does your student have a dairy allergy? (reset) Yes No Does your student have an egg allergy? (reset) Yes No
2 pc Chicken Tender #3	Student First Name Student Last Name School (reset) Pritchett-October 27 Tripp-October 20 Meridian-October 20 Aptakisic-October 27 Homeroom/Advisory Teacher* Custard flavor (reset) Vanilla Chocolate None Does your student have a dairy allergy? (reset) Yes No Does your student have an egg allergy? (reset) Yes No
2 pc Chicken Tender #4	Student First Name Student Last Name School (reset) Pritchett-October 27 Tripp-October 20 Meridian-October 20 Aptakisic-October 27 Homeroom/Advisory Teacher* Custard flavor (reset) Vanilla Chocolate None Does your student have a dairy allergy? (reset) Yes No Does your student have an egg allergy? (reset) Yes No
2 pc Chicken Tender #5	Student First Name Student Last Name School (reset) Pritchett-October 27 Tripp-October 20 Meridian-October 20 Aptakisic-October 27 Homeroom/Advisory Teacher* Custard flavor (reset) Vanilla Chocolate None Does your student have a dairy allergy? (reset) Yes No Does your student have an egg allergy? (reset) Yes No
2 pc Chicken Tender #6	Student First Name Student Last Name School (reset) Pritchett-October 27 Tripp-October 20 Meridian-October 20 Aptakisic-October 27 Homeroom/Advisory Teacher* Custard flavor (reset) Vanilla Chocolate None Does your student have a dairy allergy? (reset) Yes No Does your student have an egg allergy? (reset) Yes No
2 pc Chicken Tender #7	Student First Name Student Last Name School (reset) Pritchett-October 27 Tripp-October 20 Meridian-October 20 Aptakisic-October 27 Homeroom/Advisory Teacher* Custard flavor (reset) Vanilla Chocolate None Does your student have a dairy allergy? (reset) Yes No Does your student have an egg allergy? (reset) Yes No
2 pc Chicken Tender #8	Student First Name Student Last Name School (reset) Pritchett-October 27 Tripp-October 20 Meridian-October 20 Aptakisic-October 27 Homeroom/Advisory Teacher* Custard flavor (reset) Vanilla Chocolate None Does your student have a dairy allergy? (reset) Yes No Does your student have an egg allergy? (reset) Yes No
2 pc Chicken Tender #9	Student First Name Student Last Name School (reset) Pritchett-October 27 Tripp-October 20 Meridian-October 20 Aptakisic-October 27 Homeroom/Advisory Teacher* Custard flavor (reset) Vanilla Chocolate None Does your student have a dairy allergy? (reset) Yes No Does your student have an egg allergy? (reset) Yes No
Grilled Cheese #1	Student First Name Student Last Name School (reset) Pritchett-October 27 Tripp-October 20 Meridian-October 20 Aptakisic-October 27 Homeroom/Advisory Teacher* Custard flavor (reset) Vanilla Chocolate None Does your student have a dairy allergy? (reset) Yes No Does your student have an egg allergy? (reset) Yes No	copy
Grilled Cheese #2	Student First Name Student Last Name School (reset) Pritchett-October 27 Tripp-October 20 Meridian-October 20 Aptakisic-October 27 Homeroom/Advisory Teacher* Custard flavor (reset) Vanilla Chocolate None Does your student have a dairy allergy? (reset) Yes No Does your student have an egg allergy? (reset) Yes No
Grilled Cheese #3	Student First Name Student Last Name School (reset) Pritchett-October 27 Tripp-October 20 Meridian-October 20 Aptakisic-October 27 Homeroom/Advisory Teacher* Custard flavor (reset) Vanilla Chocolate None Does your student have a dairy allergy? (reset) Yes No Does your student have an egg allergy? (reset) Yes No
Grilled Cheese #4	Student First Name Student Last Name School (reset) Pritchett-October 27 Tripp-October 20 Meridian-October 20 Aptakisic-October 27 Homeroom/Advisory Teacher* Custard flavor (reset) Vanilla Chocolate None Does your student have a dairy allergy? (reset) Yes No Does your student have an egg allergy? (reset) Yes No
Grilled Cheese #5	Student First Name Student Last Name School (reset) Pritchett-October 27 Tripp-October 20 Meridian-October 20 Aptakisic-October 27 Homeroom/Advisory Teacher* Custard flavor (reset) Vanilla Chocolate None Does your student have a dairy allergy? (reset) Yes No Does your student have an egg allergy? (reset) Yes No
Grilled Cheese #6	Student First Name Student Last Name School (reset) Pritchett-October 27 Tripp-October 20 Meridian-October 20 Aptakisic-October 27 Homeroom/Advisory Teacher* Custard flavor (reset) Vanilla Chocolate None Does your student have a dairy allergy? (reset) Yes No Does your student have an egg allergy? (reset) Yes No
Grilled Cheese #7	Student First Name Student Last Name School (reset) Pritchett-October 27 Tripp-October 20 Meridian-October 20 Aptakisic-October 27 Homeroom/Advisory Teacher* Custard flavor (reset) Vanilla Chocolate None Does your student have a dairy allergy? (reset) Yes No Does your student have an egg allergy? (reset) Yes No
Grilled Cheese #8	Student First Name Student Last Name School (reset) Pritchett-October 27 Tripp-October 20 Meridian-October 20 Aptakisic-October 27 Homeroom/Advisory Teacher* Custard flavor (reset) Vanilla Chocolate None Does your student have a dairy allergy? (reset) Yes No Does your student have an egg allergy? (reset) Yes No
Grilled Cheese #9	Student First Name Student Last Name School (reset) Pritchett-October 27 Tripp-October 20 Meridian-October 20 Aptakisic-October 27 Homeroom/Advisory Teacher* Custard flavor (reset) Vanilla Chocolate None Does your student have a dairy allergy? (reset) Yes No Does your student have an egg allergy? (reset) Yes No
Garden Salad (no meat - veggie option) #1	Student First Name Student Last Name School (reset) Pritchett-October 27 Tripp-October 20 Meridian-October 20 Aptakisic-October 27 Homeroom/Advisory Teacher* Custard flavor (reset) Vanilla Chocolate None Does your student have a dairy allergy? (reset) Yes No Does your student have an egg allergy? (reset) Yes No	copy
Garden Salad (no meat - veggie option) #2	Student First Name Student Last Name School (reset) Pritchett-October 27 Tripp-October 20 Meridian-October 20 Aptakisic-October 27 Homeroom/Advisory Teacher* Custard flavor (reset) Vanilla Chocolate None Does your student have a dairy allergy? (reset) Yes No Does your student have an egg allergy? (reset) Yes No
Garden Salad (no meat - veggie option) #3	Student First Name Student Last Name School (reset) Pritchett-October 27 Tripp-October 20 Meridian-October 20 Aptakisic-October 27 Homeroom/Advisory Teacher* Custard flavor (reset) Vanilla Chocolate None Does your student have a dairy allergy? (reset) Yes No Does your student have an egg allergy? (reset) Yes No
Garden Salad (no meat - veggie option) #4	Student First Name Student Last Name School (reset) Pritchett-October 27 Tripp-October 20 Meridian-October 20 Aptakisic-October 27 Homeroom/Advisory Teacher* Custard flavor (reset) Vanilla Chocolate None Does your student have a dairy allergy? (reset) Yes No Does your student have an egg allergy? (reset) Yes No
Garden Salad (no meat - veggie option) #5	Student First Name Student Last Name School (reset) Pritchett-October 27 Tripp-October 20 Meridian-October 20 Aptakisic-October 27 Homeroom/Advisory Teacher* Custard flavor (reset) Vanilla Chocolate None Does your student have a dairy allergy? (reset) Yes No Does your student have an egg allergy? (reset) Yes No
Garden Salad (no meat - veggie option) #6	Student First Name Student Last Name School (reset) Pritchett-October 27 Tripp-October 20 Meridian-October 20 Aptakisic-October 27 Homeroom/Advisory Teacher* Custard flavor (reset) Vanilla Chocolate None Does your student have a dairy allergy? (reset) Yes No Does your student have an egg allergy? (reset) Yes No
Garden Salad (no meat - veggie option) #7	Student First Name Student Last Name School (reset) Pritchett-October 27 Tripp-October 20 Meridian-October 20 Aptakisic-October 27 Homeroom/Advisory Teacher* Custard flavor (reset) Vanilla Chocolate None Does your student have a dairy allergy? (reset) Yes No Does your student have an egg allergy? (reset) Yes No
Garden Salad (no meat - veggie option) #8	Student First Name Student Last Name School (reset) Pritchett-October 27 Tripp-October 20 Meridian-October 20 Aptakisic-October 27 Homeroom/Advisory Teacher* Custard flavor (reset) Vanilla Chocolate None Does your student have a dairy allergy? (reset) Yes No Does your student have an egg allergy? (reset) Yes No
Garden Salad (no meat - veggie option) #9	Student First Name Student Last Name School (reset) Pritchett-October 27 Tripp-October 20 Meridian-October 20 Aptakisic-October 27 Homeroom/Advisory Teacher* Custard flavor (reset) Vanilla Chocolate None Does your student have a dairy allergy? (reset) Yes No Does your student have an egg allergy? (reset) Yes No

Special Lunch - Culver's - October 2026 $11.00 Options: 3 pc Chicken Tender

Special Lunch Allergy Disclaimer: The D102 PTO coordinates fundraisers with outside vendors but is not responsible for food preparation, cross-contamination, or allergic reactions. Participation is at your own risk. Parents/guardians are solely responsible for verifying that vendor ingredients are safe for their child's dietary needs.

We apologize but there will be no refunds provided for absences.

PTO Refund Policy: No refunds will be given for dessert/food that has already been ordered. If dessert/food has not been ordered, a credit can be given for use on a future PTO item.