Here's your opportunity to be part of "Building YOUR YMCA...Today and Tomorrow."

Engrave my inscription as follows:
(Please print inscription as you want it to appear on the brick. Each 4 x 8 brick will have three lines (14 characters per line, including spaces.) Each 8 x 8 brick will have five lines (14 characters per line, including spaces.)

4" x 8" Brick (Lines 1,2 & 3)

8" x 8" Brick (You may add lines 4 and 5)

Purchaser's Name __________________________

Address __________________________________

City _____________ ST ___ Zip ______________

Phone: (Day) ___________(Night) ____________

Please print additional forms to order more bricks.

Please print the form and mail with payment to:

Countryside YMCA
Attn: Debra Phillips
1699 Deerfield Rd.
Lebanon, OH 45036

Thanks!