Method of Payment: q Cheque (Please make cheques payable to Assiniboine Park Conservancy) q Visa q MasterCard Mark your CREDIT CARD NUMBER milestones, EXPIRY DATE memories and NAME ON CREDIT CARD

SIGNATURE OF CARDHOLDER special occasions with Proceeds generated from the MemoryStone and ZooRock programs go towards ongoing maintenance and improvements an engraved stone at of Assiniboine Park & Zoo. MAKE YOUR Assiniboine Park.

I'd like to donate in tribute to a loved one! My donation is: (please check one if applicable): q In Memory q In Celebration q In Honour MARK TRIBUTE NAME With a MemoryStone or Please send notification tribute card to: ZooRock at Assiniboine Park. NAME

STREET ADDRESS

CITY/PROVINCE POSTAL CODE

SIGNED FROM

To order your stone, simply return this form with payment to: Assiniboine Park Conservancy 55 Pavilion Crescent assiniboinepark.ca Winnipeg, Manitoba R3P 2N6 55 Pavilion Crescent • Winnipeg, Manitoba • R3P 2N6 Or drop it off at the Pavilion at the address above. Contact Us [email protected] Phone: 204 927 8080 P 204 927 8080 Email: [email protected] TF 1 877 927 6006

Note: MemoryStones/ZooRocks are exposed to natural elements, pedestrian traffic, and other F 204 927 7201 general wear and tear which may affect both the inscriptions and the stones appearance over time. Once approved, installed MemoryStones/ZooRocks will not be removed for changes or additions to the inscription. MemoryStones/ZooRocks will remain in place until such time that the plaza/area needs to be upgraded, replaced/removed or changes to the building or space are necessary or due to circumstances beyond the control of Assiniboine Park Conservancy(APC). APC will attempt to contact 2021 the donor should such a circumstance arise. Donor Information:

NAME

STREET ADDRESS

CITY/PROVINCE POSTAL CODE

PHONE

EMAIL A unique opportunity MEMORYSTONES ZOOROCKS q Yes, I would like to receive emails about news, events, and promotions from Assiniboine Park Conservancy and understand I can unsubscribe at to have your love for anytime. AT THE ENTRANCE TO AT THE ASSINIBOINE PARK A tax receipt will be issued for the full gift amount. the Park and Zoo set THE LEO MOL SCULPTURE ZOO PLAZA GARDEN Your donation will be recognized on a ZooRock inscribed with Choose your stone: in stone! the message of your choice and installed as part of the entrance Your donation can be recognized with the inscription of your MemoryStone plaza at Assiniboine Park Zoo. You can be a part of the amazing changes choice on a MemoryStone installed at the entrance to the q Entrance to the Leo Mol Sculpture Garden at Assiniboine Park with a MemoryStone or Leo Mol Sculpture Garden, along the long entrance pathway • Large Stone (8" x 8") = $299 • Standard 4"x8" $199 q Around Riley Family Duck Pond ZooRock. between the small parking lot and the lily pond. • Standard 4" x 8" $199 • Standard Stone (4" x 8") = $199 ZooRock q Zoo Entrance AROUND THE RILEY • Large 8"x8" $299 FAMILY DUCK POND Create your personalized message: Your MemoryStone can become part of the Standard MemoryStone Character maximum: 3 lines, 14 characters each line. plaza around the Riley Family Duck Pond. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 • Standard Stone (4" x 8") = $199 Available at Available at 1 2 $199! $299! 3 Large ZooRock Character maximum: 5 lines, 14 characters each line.

1 2 3 4 5 6 7 8 9 10 11 12 13 14 1 2 3 4 5

Note: Every space and punctuation mark counts as a character. Assiniboine Park Conservancy (APC) reserves the right to deny any application that is deemed unsuitable, such as ones containing discriminatory or inappropriate messages. APC reserves the right to edit messages with the approval of the donor.