BRICK ORDER FORM Ronald McDonald House® near UChicago Medicine Comer Children’s Hospital

To purchase a brick, please complete this order form and return it, with payment, to:

RMHC-CNI Attn: Mardelle Gundlach 5444 S. Drexel Avenue Chicago, IL 60615 MGundlach@rmhccni.org 773-324-5437

Name: ________________________________________________________________________________

Street: ________________________________________________________________________________

City, State, Zip: _________________________________________________________________________

Phone: ________________________________________________________________________________

Email: _________________________________________________________________________________

Please indicate the type and quantity of bricks you wish to order:

Full Brick: Quantity: ________ at $500 each

Half Brick: Quantity: ________ at $250 each

Total Order: $_________ for #_________ bricks

Payment Options: * Please include brick order form with your payment.

Check Please make payable to ‘RMHC-CNI’

Credit Card AMEX VISA Mastercard Discover

3-Digit Security Code: ____________________Exp. Date: ____________________

Card Number: ________________________________________________________

Signature: ____________________________________________________________

Your gift will help keep families together

Please complete your message based on the size of brick you would like to purchase.

Place one letter or punctuation mark in each box and leave blank boxes for spaces. All text will be centered. Please use a separate form to purchase more than one brick of

Your gift will help keep families together

BRICK ORDER FORM Ronald McDonald House® near UChicago Medicine Comer Children’s Hospital

Full Brick (8”x8”) 6 lines - 13 characters per line

Half Brick (4”x8”) 3 lines - 13 characters per line