<p> THEODORE ROOSEVELT HIGH SCHOOL DES MOINES, IOWA</p><p>CUMMINGS COURTYARD BRICK ORDER FORM "Building for the future with bricks from the past"</p><p>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!</p><p>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.</p><p>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</p><p>Purchaser First/Last Name Phone Number</p><p>Complete Address</p><p>INSCRIPTION</p><p> 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.</p><p> This is part of a sequential set – placement number _____ of _____.</p><p>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.</p><p>Thank you! ** Orders must be received by MAY 5, 2016 **</p><p>Revised: 04/05/16</p>