Memorial Gift Brick Form

Memorial Gift Brick Form

lombardparks.com | (630) 627-1281 Please complete this form and Administrative Assistant, Emily Miller will reach out to confirm your request and provide options for payment. Please note, there is no guaranteed installation date for your brick and brick will not be processed until payment is received. For additional information, call (630) 627- 1281.
Purchaser Information
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail
example@example.com
Phone Number*
Brick Location

Lilacia ParkWith a Memorial Tree
Lombard Park District reserves the right to edit text and determine the locations of the bricks.

The exact installation date is not guaranteed. The purchaser will be notified when the brick is installed. The park district supplies and installs the bricks, but is not responsible for lost or damaged bricks.
Brick Details
Brick Size Options
Brick Custom Engravement:

4" by 8": 16 characters across with two lines of text

8" by 8": 16 characters across with five lines of text

12" by 12": 16 characters across with six lines of text
Please type the text you would like on your brick:
Do you have any additional comments?
Please verify that you are human
Should be Empty:

Purchaser Information