~ OR ~
Click here for a PDF printable version of the order form. You may order Single Bricks (4”x 8”) and Double Bricks (8”x 8”) with this form. Each surface will be laser printed with 5/8″ text. (Note: If you’re unable to open PDF files, you can simply print this page, fill in the information and mail the completed form with your check to the address at the bottom of this page.)
Single Bricks: You’re allowed three (3) lines with 20 characters per line (including spaces).
Double Bricks: You’re allowed six (6) lines with 20 characters per line (including spaces).
Clip Art: For available free clipart and where it can be used on your brick, please click here.
Please provide us with your contact information below:
Name: ____________________________________________ Address:_____________________________________________
City: ________________________State: ____ Zip: ________
Email Address: ________________________________________
YOUR BRICK INFORMATION
Please PRINT your brick information clearly and
exactly as you want it to appear on your brick(s).
“We love & miss you”
Single Brick (20 characters per line including spaces)
Line 1 ___________________________________________________
Line 2 ___________________________________________________
Line 3 ___________________________________________________
Double Brick (20 characters per line including spaces)
Line 1 __________________________________________________
Line 2 __________________________________________________
Line 3 __________________________________________________
Line 4 __________________________________________________
Line 5 __________________________________________________
Line 6 __________________________________________________
A maximum of six (6) single bricks or three (3) double
bricks may be ordered for each of your lost loved ones.
A separate order form is required for each brick ordered.
Please place a check by the appropriate option(s) below and make your check payable to either Our Children’s Memorial Walkway or OCMW.
___ Enclosed is my check for $ _________ for ___ SINGLE BRICK(s) @ $50 each
___ Enclosed is my check for $ _________ for ___ DOUBLE BRICK(s) @ $100 each
___ Enclosed is a special gift of $ ___________ to be used in maintaining the Walkway and Garden. I am a member of the following group: _________________________________ .
___ 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 you to send them a card. Their name & address are:
After completing this form, please mail it along with your check to:
Our Children’s Memorial Walkway, Inc.
PO Box 44153
Charlotte, NC 28215