Brick x Brick Scholarship Program | Brick Order Form

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4. This scholarship is used “To promote and encourage academic achievement and life-long learning among Richton Park residents.” The scholarship is awarded to high school seniors headed to a college or university, those currently enrolled, and or adult students furthering their education.

6. The bricks that will be installed in front of the community center will serve as your support for the importance of continuing education as well as advertisement for your business or organization. Families are encouraged and welcomed to honor family members, friends, and loved ones as well! Bricks can be inscribed as a dedication, a memorial, an organization’s name/logo, or a message of encouragement.

8. Name / Organization*

9. City, State*

11. Email Address*

12. Phone*

16. Type/Size of Brick*

    1. 4X8 BRICK - 3 LINES - 13 CHARACTERS PER LINE @ $100.00 PER BRICK
    2. 12X12 BRICK - 6 LINES - 18 CHARACTERS PER LINE @ $500.00 PER BRICK

18. Icons are available at no additional charge (2 icons per brick). Please allow 3 spaces on 2 lines for each icon, indicate placement below.

20. 4x8 Brick Guide
    

21. 12x12 Brick Guide
    

23. Please enter desired 4x8 brick engraving based on guide above. [Hit Enter] for next line.

24. Please enter desired 12x12 brick engraving based on guide above. [Hit Enter] for next line.

26. Upload Logo/Icon

30. Completion of this order form will take you directly to checkout to complete your purchase. There, make sure to include:
    - Description of payment being applied: Brick by Brick, Name, Size (4x8 or 12x12) - Misc Fee: $100.00 or $500.00

    - Description of payment being applied: Brick by Brick, Name, Size (4x8 or 12x12) - Misc Fee: $100.00 or $500.00

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33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit

* indicates a required field