Yes, I/we accept the opportunity to place a brick and/or a bench in the Dalton and Ruby Proctor 4-H Clover Courtyard and State Council Walkway at the Eastern 4-H Environmental Education Conference Center.

Name:______________________________________________________ County ________________

Address __________________________ City ____________________ State_______ Zip __________

Telephone (home): _________________ (work) ________________ e-mail: ____________________

Please complete the following information for each gift you wish to purchase (minimum of $100/each). Please designate whether the gift is for a brick or bench by circling your preference.

Each brick has three lines with up to 17 characters, spaces count as characters:

Option One:   Brick        Bench (circle one)

(Line 1) _______________________ (up to 17 characters)

(Line 2) _______________________ (up to 17 characters)

(Line 3) _______________________ (up to 17 characters)

Option Two (to honor someone special):   Brick       Bench (circle one)

(Line 1) In honor of

(Line 2) _______________________ (up to 17 characters)

(Line 3) _______________________ (up to 17 characters)

Option Three (in memory of someone special):   Brick          Bench (cirlce one)

(Line 1) In memory of

(Line 2) _______________________ (up to 17 characters)

(Line 3) _______________________ (up to 17 characters)
 

Please send a gift acknowledgement card with the courtyard graphic to the following: (Print)

Name ____________________________________________

Address __________________________________________

_________________________________________________

Telephone number (h) __________________   (w) ________________  email __________________

Payment:
Sub-total  $______________($100/brick)

                $______________($500/bench)

Total Combined Amount Enclosed $______________

( ) Check payable to North Carolina 4-H Development Fund

( ) VISA ( )MasterCard #_________________________________ Exp. Date___________

Name as it appears on Card __________________________________________________
Signature_________________________________________________________________

( )Please send me information about other gift opportunities at the Eastern 4-H Environmental Education Center.

( )Please send me information about other giving opportunities for the 4-H program.