William R. Boone High School Foundation

 "Memory Brick" Order Form

          Purchaser Name: _________________________________________(________________)     if BHS, Class of: _______

                                 First                   Middle                     Last                         Maiden

          _____ Graduate/Former Student     _____ Faculty/Staff        _____Parent/Friend        ______Corporate

          Address: _______________________________________  City: _________________ State: ___  Zip: ______________

          Home Phone: ________________ Cell Phone: ________________ 

          Work Phone: ________________ Employer: _______________________________ Position/Title:  _________________

          Brick Personalization - three lines per brick, 13 characters per line, including spacers and punctuation:

          Brick One:

          Line 1: ____  ____  ____  ____  ____  ____  ____  ____  ____  ____  ____  ____  ____ ____

          Line 2: ____  ____  ____  ____  ____  ____  ____  ____  ____  ____  ____  ____  ____ ____

          Line 3: ____  ____  ____  ____  ____  ____  ____  ____  ____  ____  ____  ____  ____ ____

          Brick Two:

          Line 1: ____  ____  ____  ____  ____  ____  ____  ____  ____  ____  ____  ____  ____ ____

          Line 2: ____  ____  ____  ____  ____  ____  ____  ____  ____  ____  ____  ____  ____ ____

          Line 3: ____  ____  ____  ____  ____  ____  ____  ____  ____  ____  ____  ____  ____ ____

          Brick Three:

          Line 1: ____  ____  ____  ____  ____  ____  ____  ____  ____  ____  ____  ____  ____ ____

          Line 2: ____  ____  ____  ____  ____  ____  ____  ____  ____  ____  ____  ____  ____ ____

          Line 3: ____  ____  ____  ____  ____  ____  ____  ____  ____  ____  ____  ____  ____ ____

          Brick Four:

          Line 1: ____  ____  ____  ____  ____  ____  ____  ____  ____  ____  ____  ____  ____ ____

          Line 2: ____  ____  ____  ____  ____  ____  ____  ____  ____  ____  ____  ____  ____ ____

          Line 3: ____  ____  ____  ____  ____  ____  ____  ____  ____  ____  ____  ____  ____ ____

          Your contribution:  ____$100   ____$75   ____$50   _____$Other  ( ____ Does your company have a matching gift program?)

          Contribution - $50 minimum, $25 for current BHS students

          Please make checks payable to: Boone Foundation Brick Campaign

          Mail to: Boone Foundation Brick Campaign
          2000 S. Mills Avenue
          Orlando, FL 32806