Patriot's Park Brick Order Form

I/We are Bereaved Parent(s) Name(s): ______________________________Other __________________

Mailing Address: ______________________________________________________________________

City: ___________________ State: _____ Zip: _________ Telephone: ( )_____________________

Child(ren)’s Name(s): _______________________________________________ Age(s):_____________

Birth Date(s) ________________________________ Death Date(s)______________________________

Cause of Death(s) ________________________________Symbol(s)_____________________________

E-mail Address_________________________ Website________________________________________

There are approximately 50 bricks available.

Please PRINT order form (this cannot be done through the website) and return with payment to:

Mrs. Dinah Taylor

804 Main Street

Williamsburg, KY 40769

If you would like to pay with a credit card, please call the President’s Office at 606-539-4201 and tell them you would like to order a brick for Patriot's Park. Make all checks payable to Cumberland College for Patriot's Park. The bricks measure 4 x 8 x 1 ¼" and will allow for 14 to 15 print spaces. Letters, commas, spaces, etc. are considered print spaces.

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Brick # 1

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Jim Taylor, II

7/26/72 - 5/20/91

Pegasus

Brick # 2

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___ I am donating a brick in honor or memory of another family and want you to send a card to:

Name ________________________________ Address_______________________________________

City ___________________ State ________ Zip ___________

Enclosed is my check in the amount of $ ____________ for ________ brick(s) @ $50.00 each