Donor Brick Order Form

Donor Tile Order Form

If you have access to Adobe Acrobat Reader, please click on Donor Tile Order Form and print. Otherwise you can print and complete the form below to order a donor brick. At the bottom of this page are examples.

Name

Circle: Alum Family Current Family

Grandparent(s) Extended Family

Staff Friend Business

Address

City

State Zip

Phone

E-Mail

Indicate number of bricks requested:

# Individual x $50 each =$

# Family x $100 each = $

Total: $

Make check or money order payable to:

“St Rose of Lima School”

Complete & return this order form and payment to:

St Rose of Lima School

1345 W. Dakota Ave

Denver, CO 80223

 Individual Tile – $50 each – 4” x 8”

Includes: Up to three (3) lines of engraved text, up to 20 characters per line

Note: a character = a letter, a number, a punctuation mark, and/or a space

Line 1

Line 2

Line 3

 Family Tile – $100 each – 8” x 8”

Includes: Up to five (5) lines of engraved text, up to 20 characters per line

Note: a character = a letter, a number, a punctuation mark, and/or a space

Line 1

Line 2

Line 3

Line 4

Line 5

Send mail to with questions or comments about this web site. Last modified: October 23, 2007

Send mail to with questions or comments about this web site.
Last modified: October 23, 2007