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Independence, Inc.
Independent Living Resource Center 
 Serving People with Disabilities Since 1978  

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Buy a Brick for the Path to Independence

Honor, memorialize, or remember someone special with a custom engraved brick. Through the purchase of a brick, you will create a lasting tribute to an individual, group, or a favorite phrase. Immortalize a friend, family member, a special date, or even a pet. These bricks will become a permanent part of the courtyard at the new Independence, Inc.

 Only 240 engraved bricks will be sold. 

To order a brick

Print out and complete this form and mail it to:
Independence, Inc.
2001 Haskell Ave.
Lawrence, KS 66046
(Sorry - no on-line orders)

_____Yes, I want to build a path to independence.
Enclosed is my check for $100 for each brick.

_____Yes, I want to help even more.
I've added a donation of $_________ to my purchase. I want the path to independence to be smooth and sure.

_____ I won't be purchasing a brick but I am enclosing a donation of $____________ for Independence, Inc. to use as needed for the capital campaign.

Print your name or message in the spaces below. There is a maximum of 14 characters per line and a maximum of three lines per brick. Be sure to leave a blank space between words or wherever you want a space. Be sure to check the spelling! Bricks will be engraved exactly as printed. However, we reserve the right to refuse orders of questionable taste.

Enter Message Below: (Remember each short line represents a character or space.)

___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
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Name:_____________________________________________________

   Address:_____________________________________________________

         City: _________________________   State: _____   Zip:_________ _

Make checks payable to INDEPENDENCE, INC.
Send this form & your check to the address given above.

For more information contact us at 785/841-0333. 

Thanks!

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