Memorial Brick Order Form

Create a lasting tribute to a loved one or honor someone special with an inscribed 4 by 8-inch brick on one of our brick walkways at the Hospice Home at High Point or the Randolph Hospice House gardens.

Each inscription includes a maximum of 18 characters (including spaces and punctuation) and three lines per brick. Each line will automatically be centered on the brick and engraved in all caps.

Each fall, the organization installs new bricks donated during the previous year. Donors will receive a notification about a dedication ceremony. Please contact the Hospice development office at 336.889.8446 with any questions.

Your Information
Name*
First Last Suffix
Email Address*
Phone Number*
Credit Card Billing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Your Brick Inscription
Your inscription can include up to 3 lines with up to 18 characters (including spaces and punctuation) per line. Each line will automatically be centered on the brick.
Line 1*
Line 2
Line 3
Brick to be installed at:*
- High Point location
- Asheboro location
Special instructions:
Would you like to notify someone of this gift?*
- Yes
- No
This gift is from:
Notification Information
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
This gift is from:*
Special Instructions
Gift Information
Brick Gift Amount
Price:
Additional Gift Amount (optional)
Total
$0.00
Billing Information*

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
Is the mailing address for acknowledgement of this gift the same as above?
- Yes
- No
Mailing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
CAPTCHA
Thank you for your gift to Hospice of the Piedmont in High Point, NC.
Email
This field is for validation purposes and should be left unchanged.

Memorial Brick Order Form

Your Information

Your Brick Inscription

Notification Information

Gift Information