Crocker/Riverside Elementary School CUB Campaign Brick Reservation Form

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Please fill out this form for each brick you are purchasing to support the C/R Campus Upgrade and Beautify campaign. The cost is $150 per brick. Please make payment to @Crocker-Riverside on Venmo or mail a check made out to "Crocker/Riverside PTO" to 800 8th Avenue, Sacramento, CA 95818

Email *

Your full name *

Your email *

Your phone number *

What is your connection to Crocker/Riverside? *

Parent/Guardian

Related to a child at C/R

Community Member

Other:

What text would you like printed on the brick? (3 lines with 15 characters per line - PLEASE USE ALL CAPS) LINE 1: *

What text would you like printed on the brick? (3 lines with 15 characters per line - PLEASE USE ALL CAPS) LINE 2:

What text would you like printed on the brick? (3 lines with 15 characters per line - PLEASE USE ALL CAPS) LINE 3:

I made payment to: *

Venmo

Mailed a Check

I've not made payment yet

Other:

A copy of your responses will be emailed to the address you provided.

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