Jefferson High School is a non-profit organization

You Must be a former Varsity Letterwinner to be eligible for a brick

(Please print)

You Must be a former Varsity Letterwinner to be eligible for a brick

Enclose your tax-deductible contribution with this order form. Make checks payable to Jefferson High School. A receipt will be mailed to you.

Questions should be directed to:
Scott Kibby
319-558-2148
319-398-2149 (fax)

$100 Brick Order Form

Please fill out the order form to indicate how you would like your brick to appear and mail to:

Name                                                                                     

Address                                                                                

Home phone                                                                       

Work phone                                                                          

E-mail                                                                                       

 Fill in the name you want etched on your brick. Wording is automatically centered on the brick.

1st line: (Please print upper case block letters. Use up to 18 spaces, leaving a space between names).

Write it here                                                                                                                 

2nd line: (Graduation year)

write it here                                                                                                                 

 Jefferson High School Activities Office
1243 20th St SW
Cedar Rapids IA 52404

You Must be a former Varsity Letterwinner to be eligible for a brick

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