BRICK ORDER FORM Ronald McDonald House ® near UChicago Medicine Comer Children’s Hospital To purchase a brick, please complete this order form and return it, with payment, to: RMHC-CNI Attn: Mardelle Gundlach 5444 S. Drexel Avenue Chicago, IL 60615 [email protected] 773-324-5437 Name: ________________________________________________________________________________ Street: ________________________________________________________________________________ City, State, Zip: _________________________________________________________________________ Phone: ________________________________________________________________________________ Email: _________________________________________________________________________________ Please indicate the type and quantity of bricks you wish to order: Full Brick: Quantity: ________ at $500 each Half Brick: Quantity: ________ at $250 each Total Order: $_________ for #_________ bricks Payment Options: * Please include brick order form with your payment. Check Please make payable to ‘RMHC-CNI’ Credit Card AMEX VISA Mastercard Discover 3-Digit Security Code: ____________________Exp. Date: ____________________ Card Number: ________________________________________________________ Signature: ____________________________________________________________ Your gift will help keep families together