Brick Memorial Form

"A Special Memory" Memorial Brick Order Form

Create an everlasting memory of your loved one with an engraved brick at the
Hospice Alliance Memorial Brick Walk located at the Kemper Center.

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number*

Area CodePhone Number

E-mail*

Please enter the message you would like displayed on your Remembrance Brick below.

	1	2	3	4	5	6	7	8	9	10	11	12	13	14	15	16	17	18	19
1
2
3
4
5
6
7

Enclose your check, payable to Hospice Alliance Foundation.
Mail to: Hospice Alliance, 10220 Prairie Ridge Blvd., Pleasant Prairie, WI 53158
For more information, call Megan Frazer at (262) 652-4482 X1253.

Each June, families are welcomed to our annual Remembrance Service and Memorial Brick Dedication. Here, they reconnect with caregivers and stroll the pathway
completed with commemorative bricks.

After clicking "Submit," you will be automatically redirected
to our donation page to complete your order with a payment.