Theodore Roosevelt High School

THEODORE ROOSEVELT HIGH SCHOOL DES MOINES, IOWA

CUMMINGS COURTYARD BRICK ORDER FORM "Building for the future with bricks from the past"

Imagine you or your family's name forever immortalized at Roosevelt. Need a great gift idea? Personally engraved bricks make wonderful gifts for graduation and other memorable celebrations!

Roosevelt maintains a memorial brick courtyard east of the library in honor of Bob Cummings, a former Roosevelt math teacher. Personally engraved bricks are available for $50 each.

If you are interested in purchasing a personally engraved brick, please return this form to the Roosevelt main office: Cummings Courtyard Brick Order c/o Roosevelt High School 4419 Center Street Des Moines, Iowa 50312-2299

Purchaser First/Last Name Phone Number

Complete Address

INSCRIPTION

 You may use up to two rows of 18 characters in each line.  Leave spaces between words and punctuation marks may be included as a character.  Arrange the information as you want it to appear on the brick – proof for accuracy!  PLEASE PRINT IN UPPER CASE LETTERS and or NUMBERS.  If ordering more than one brick as a set, place sequence numbers on order form.  Finished bricks will be placed directly in the courtyard.

 This is part of a sequential set – placement number _____ of _____.

Please make checks out to Roosevelt High School Brick Fund. If you would like a receipt, please include a self-addressed, stamped envelope. Receipts will be issued when placing orders in person.

Thank you! ** Orders must be received by MAY 5, 2016 **

Revised: 04/05/16