Brick Campaign 8" x 8" Inaugural Tile Order Form

Simply fill out the form below and mail your payment of $200 to:

Brick Memorial Program
Wayside House, Inc.
378 N.E. Sixth Avenue
Delray Beach, FL 33483

You may also place an order by phone, Monday through Friday, 9:00 am to 4:30 pm, at 561-278-0055, or send your payment online through PayPal.

* inidcates a required field.

Name *
Address	City	State / Zip
		/
Phone *	Email *
Our 8" x 8" inaugural tiles can hold up to 5 lines of text. Maximum 13 characters and spaces per line.