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Share Brick

Commemorative Bricks encircle the Hospice of Palm Beach County Angel Statue. They are a tribute to the memory of your beloved child, who can be any age, from parents, grandparents, siblings and other loved ones and will become a permanent part of the children's memorial at Kelsey Park in Lake Park. Bricks are sold for $100 each with the proceeds supporting the SHARE Program.

Title:
First Name: *
Last Name: *
Street: *
City: *
State: *
Zip: *
Phone Number: *
Email: *

I/We wish to make a tax-deductable donation of: *

   
Please complete the information as you wish it to appear on your brick:
(20 characters per line maximum including spaces and punctuation - three lines maximum)
   

Billing Information  
   
Name as it appears on the Credit Card: *
Type of credit card: *
Credit Card Number: *
Expiration Date: (1203) *
Billing Street: *
Billing City: *
Billing State: *
Billing Zip Code: *

Online Payments

Note: * Items in with an asterik are required

A COPY OF THE OFFICIAL REGISTRATION, (#CH2376), AND FINANCIAL INFORMATION MAY BE OBTAINED FROM THE DIVISION OF CONSUMER SERVICES BY CALLING TOLL-FREE (800-435-7352) WITHIN THE STATE OF FLORIDA. REGISTRATION DOES NOT IMPLY ENDORSEMENT, APPROVAL, OR RECOMMENDATION BY THE STATE.

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