Student Lunch Order Form

Student Lunch Order Form
Name ____________________________________________________Grade ______________
(one student per order form, please)
Directions: Fill in meal choice on appropriate day with corresponding letter (A, B or C, etc.). Please
return order form with payment to school office in an envelope marked "School Lunch" by 12:00 Noon
Friday week prior to receiving lunch. Exact amount only (no change given), cash or checks (one per
family order) accepted.
Tuesday - Pizza Hut $1.50/slice ( A ) Cheese ( B ) Pepperoni
Wednesday - Moes $3.75 (meal includes nachos/salsa)
( C ) 2 Soft Tacos - Beef ( E ) Beef Burrito
( D) 2 Soft Tacos - Chicken ( F ) Chicken Burrito
Thursday - Country Breeze
(please use attached order form to indicate choices, one per week)
( G ) $3.50 Sandwich w/chips and salad or Jello
( H ) $3.00 Sandwich w/chips
Friday - Popeyes (meal includes biscuit)
( I ) $2.75 Leg/Thigh
( J ) $3.25 Leg/Thigh/Mashed potatoes
( K ) $3.25 Chicken Strips (2)
( L ) $3.75 Chicken Strips (2)/Mashed potatoes
4
October
Tuesday Wednesday Thursday Friday
5
6
7
________/________
# Slice A or B
________________
(Meal Choice)
________________
(Meal Choice)
________________
(Meal Choice)
11
________/________
# Slice A or B
12
________________
(Meal Choice)
13
________________
(Meal Choice)
14
Grandparent's Day
1:00 Dismissal
No Lunch Served
18
19
20
21
25
________/________
# Slice A or B
________________
(Meal Choice)
26 - No Lunch for
Middle/High School
________________
(Meal Choice)
27 - No Lunch for
Middle/High School
________________
(Meal Choice)
28 - No Lunch for
Middle/High School
________/________
# Slice A or B
________________
(Meal Choice)
________________
(Meal Choice)
________________
(Meal Choice)
Total Amount Due $ __________________

Country Breeze Options
(one order form per week)
Student Name __________________________________ Grade ___________
(one order per student)
Date: October 6
( G ) ______ Sandwich w/chips, salad or jello Meat (choose one)
( H ) ______ Sandwich w/chips ______ Ham ______ Turkey ______ Roast Beef
Choice of Chips (choose one)
Cheese (choose one)
______ Regular ______ BBQ ______ American ______ Provolone ______ Swiss
Toppings (as many as you want)
____ Mayo ____ Lettuce ____ Tomato ____ Onion ____Sweet Pickles ____ Dill Pickles
____ Oregano ____ Salt ____ Pepper ____ Yellow Sweet Peppers ____ Hot Peppers
Choice of Salad/Jello (if ordering option G) (choose one)
____ Potato ____ Macaroni ____ Lime Jello w/pears
*************************************************************************************************************
Student Name __________________________________ Grade ___________
(one order per student)
Date: October 13
( G ) ______ Sandwich w/chips, salad or jello Meat (choose one)
( H ) ______ Sandwich w/chips ______ Ham ______ Turkey ______ Roast Beef
Choice of Chips (choose one)
Cheese (choose one)
______ Regular ______ BBQ ______ American ______ Provolone ______ Swiss
Toppings (as many as you want)
____ Mayo ____ Lettuce ____ Tomato ____ Onion ____Sweet Pickles ____ Dill Pickles
____ Oregano ____ Salt ____ Pepper ____ Yellow Sweet Peppers ____ Hot Peppers
Choice of Salad/Jello (if ordering option G) (choose one)
____ Potato ____ Macaroni ____ Lime Jello w/pears
*************************************************************************************************************
Student Name __________________________________ Grade ___________
(one order per student)
Date: October 20
( G ) ______ Sandwich w/chips, salad or jello Meat (choose one)
( H ) ______ Sandwich w/chips ______ Ham ______ Turkey ______ Roast Beef
Choice of Chips (choose one)
Cheese (choose one)
______ Regular ______ BBQ ______ American ______ Provolone ______ Swiss
Toppings (as many as you want)
____ Mayo ____ Lettuce ____ Tomato ____ Onion ____Sweet Pickles ____ Dill Pickles
____ Oregano ____ Salt ____ Pepper ____ Yellow Sweet Peppers ____ Hot Peppers
Choice of Salad/Jello (if ordering option G) (choose one)
____ Potato ____ Macaroni ____ Lime Jello w/pears

Country Breeze Options
(one order form per week)
Student Name __________________________________ Grade ___________
(one order per student)
Date: October 27
( G ) ______ Sandwich w/chips, salad or jello Meat (choose one)
( H ) ______ Sandwich w/chips ______ Ham ______ Turkey ______ Roast Beef
Choice of Chips (choose one)
Cheese (choose one)
______ Regular ______ BBQ ______ American ______ Provolone ______ Swiss
Toppings (as many as you want)
____ Mayo ____ Lettuce ____ Tomato ____ Onion ____Sweet Pickles ____ Dill Pickles
____ Oregano ____ Salt ____ Pepper ____ Yellow Sweet Peppers ____ Hot Peppers
Choice of Salad/Jello (if ordering option G) (choose one)
____ Potato ____ Macaroni ____ Lime Jello w/pears