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Memorial Hermann Prevention and Recovery Center _PaRC_ Brick and


									Memorial Hermann Prevention and Recovery Center (PaRC)
Brick and Bench Campaign Order Form

Your inscription must fit into the white boxes below, 1 character per box. Each brick or plaque for a bench can have a maximum of 16
characters per line. A character is defined as a letter or number, a space or punctuation mark. Please do not use special characters.

      4”x8” - $100 Personalized Brick                                          8”x8” - $250 Personalized Brick

             $2,500      Personalized Bench

                                                                           For more information on the brick and bench campaign, please
                                                                           contact Cissy Garcia at 713.704.4264 or

Payment:     4x8 @ $100 = $_______           8x8 @ $250 = $_______             Bench @ $2,500 = $ ________       Total = $_______
Donor Information                                                          Method of Payment
Name: ____________________________________________________                 Check: Make check payable to Memorial Hermann Foundation
Address: __________________________________________________                Credit Card:        Visa    MasterCard     AmEx          Discover
City, State, Zip: _____________________________________________ Name on Card: __________________________________________
Phone: ____________________________________________________ Card Number: ___________________________________________
Email: ____________________________________________________                Expiration Date: _________________________________________

           Please mail or fax completed form along with check or credit card information to:          Memorial Hermann Foundation
                                                                                                      929 Gessner, Suite 2650
                                                                                                      Houston, Texas 77024
                                                                                                      713.242.4404 fax

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