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To Order
You may order single bricks (4"x8") or double bricks (8"x8"). You may order one brick per name submitted. Each brick surface will be laser printed with text 5/8" high. There can be three lines with 20 characters per line, including spaces on single bricks and six lines on double bricks. Please print clearly each name exactly as you want it to be printed on your brick(s).

Please print this page, or contact one of our sponsors for a form. Make checks payable to either Our Children's Memorial Walkway or OCMW.
Mail to one of your local grief support groups or to one of our sponsors.

Name:_______________________________________________________

Address:_____________________________________________________

City:_____________________________State:______Zip:______________

Phone:_______________________________________________________


___Enclosed is my check for $_________for_____single bricks @ $50.00 each, or ______double bricks @ $100.00 each.

___Enclosed is a special donation of $________.

I am a member of the following support group:_________________________

Brick # 1
Line 1 __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
Line 2 __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
Line 3 __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Brick # 2
Line 1 __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
Line 2 __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
Line 3 __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Double Brick
Line 1 __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
Line 2 __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
Line 3 __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
Line 4 __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
Line 5 __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
Line 6 __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Example
Jeff Mudge
"Deeply Missed"
1-17-61 10-04-87
___I need help in financing a brick (If sufficient funds come in, aid will be available)

___I am donating in honor of another family & want to send them a card. Their name & address:
____________________________________________________________
____________________________________________________________
____________________________________________________________


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