The Miguel Keith Project

Application for Memorial Bricks at Miguel Keith Park

$100 donation per brick

The Miguel Keith Project Memorial Brick Application Form

"*" indicates required fields

Applicant Information

Name*

First Name Last Name

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Phone*

Memorial Brick ($100 each)

Please indicate the number of bricks.

Price: $100.00

Brick Information

Please enter exactly what you wish engraved on brick in the spaces below. Blank spaces count as a space. There are 3 lines available with 16 spaces per line.

Brick 1

Line 1

Please enter the copy you would like displayed on line 1 of first Brick.

Line 2

Please enter the copy you would like displayed on line 2 of first Brick.

Line 3

Please enter the copy you would like displayed on line 3 of first Brick.

Brick 2

Line 1

Please enter the copy you would like displayed on line 1 of second Brick.

Line 2

Please enter the copy you would like displayed on line 2 of second Brick.

Line 3

Please enter the copy you would like displayed on line 3 of second Brick.

Brick 3

Line 1

Please enter the copy you would like displayed on line 1 of third Brick.

Line 2

Please enter the copy you would like displayed on line 2 of third Brick.

Line 3

Please enter the copy you would like displayed on line 3 of third Brick.

If you would like to help with the merchant credit card processing fee, please click “Apply”.

Convenience Fee (Display Only)

If you would like to help with the merchant credit card processing fee, please click “Apply”.

Apply

Convenience Fee (Calculation)

Price: $0.00

Total