HELP US BUILD A FOUNDATION

Become a part of a lasting tribute to the Free Medical Clinic of Greater Cleveland by purchasing a personalized paver brick for our new facility. These epoxy-filled engraved pavers will be added to the front entrance walkway of The Free Clinic as a permanent recognition of your sponsorship.

Cost of Engraved Paver
$100 ($80 tax-deductible)

Sample Paver

Paver examples
You may print out, complete, and mail this form to The Free Clinic at the address below;
or, if you have questions, please e-mail or call our development office at (216) 707-3405.

Paver Brick Order Form

Purchaser’s Name:  
Street Address:  
City, State, Zip:  
Phone:  
Fax:  
Email:  

Information to be engraved on 4" X 8" Paver
Up to 14 characters per line, per paver. Spaces and punctuation are considered characters.
Please print clearly and do not add boxes.

row of blocks
row of blocks
row of blocks

3 LINES, 14 CHARACTERS PER LINE
(including punctuation and spaces)

Payment Information

Payment Amount    $________________________________

Visa visa (    ) MasterCard mc (    ) American Express amex (    )

Card#    __________________________________________________    Expiration Date     __________ / __________

Check or Money Order Enclosed  (    )

Make payable to:
The Free Clinic of Greater Cleveland
12201 Euclid Avenue
Cleveland, OH 44106
Attention: Development Office

For Office Use Only

Date Received __/__/__ Brick Number ______

© The Free Medical Clinic of Greater Cleveland