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Legacy Brick Order Request
After you fill out this order request, your order will not be complete without payment.
Payments will only be accepted in the
form of cash or checks
(made out the the
MHS History Club
).
T
hese can be mailed to the
MHS History Club 3600 Avenue of the Cities Moline, IL
or dropped off in the main office in Trent Lamphier's mailbox.
If you have any questions, please contact Trent Lamphier at
tlamphie@molineschools.org
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* Indicates required question
Email
*
Your email
First and Last Name
*
Your answer
Phone Number (###-###-####)
Your answer
How many Legacy Bricks would you like to purchase? (Reminder, the price is $50.00 each)
*
1
2
3
4
5
more than 5
Required
Name to Appear on Brick One and Year (Optional)
Your answer
Brick One Inscription/Dedication
*Note - There is a 15 word limit placed on each brick
*
Your answer
Name to Appear on Brick Two and Year (Optional)
Your answer
Name to Appear on Brick Two and Year (Optional)
Your answer
Brick Two Inscription/Dedication
*Note - There is a 15 word limit placed on each brick
Your answer
Name to Appear on Brick Three and Year (Optional)
Your answer
Brick Three Inscription/Dedication
*Note - There is a 15 word limit placed on each brick
Your answer
Name to Appear on Brick Four and Year (Optional)
Your answer
Brick Four Inscription/Dedication
*Note - There is a 15 word limit placed on each brick
Your answer
Name to Appear on Brick Five and Year (Optional)
Your answer
Brick Five Inscription/Dedication
*Note - There is a 15 word limit placed on each brick
Your answer
Questions and comments
Your answer
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