Memorial Brick Order Form

A Special Memory...

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

When you purchase an engraved brick to be placed at Kemper Center, your special tribute also helps support Hospice Alliance's mission of adding life to days and to continue to provide exceptional care and supportive services to all,
regardless of ability to pay.

Brick Grid Message - Use the grid below to spell out the message for your brick. Punctuation and spaces count as characters. Please make sure we can distinguish between capital and small-case letters in the spaces below, if you choose to use both.

Please enter the message and/or names you would like displayed
on your Remembrance Brick in the form below.

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Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Phone Number*

E-mail*

example@example.com

May we send you an email here and there with our latest news, upcoming events, and opportunities for support? (You may easily unsubscribe at any time.)

Yes

To pay by check, complete and print this form and mail with 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.

To pay by credit card, fill in the form above,
click submit below and you will be automatically redirected
to our donation page to complete your order with a payment.

Service of Remembrance
and Memorial Brick Dedication
Honoring the memory of your loved one.

Each June, friends and families are welcomed to our Annual Service of Remembrance & Memorial Brick Dedication at the Kemper Center in Kenosha, Wisconsin. To receive a formal invitation, please contact our Bereavement team at bereavement@hospicealliance.org or call (262) 652-4482 ext. 1211.