Memorial Brick Order Form

A Special Memory...

Create an everlasting memory of your loved one with an engraved brick at the Hospice Alliance Memorial Brick Walk.

When you purchase an engraved brick to be placed on our Brick Walk at Kemper Center, your tribute helps support Hospice Alliance's not-for-profit mission: adding life to days and providing exceptional care and supportive services to all, regardless of ability to pay.

Brick Grid Message - Use the grid below to spell out the message for your brick. Punctuation and spaces count as characters. Please make sure we can distinguish between upper and lowercase letters in the spaces below, if you choose to use both.

Please enter the message and/or names you would like displayed on your remembrance brick in the form below.

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Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Phone Number*

E-mail*

example@example.com

May we send you an email here and there with our latest news, upcoming events, and opportunities for support? (You may easily unsubscribe at any time.)

Yes

To pay by check, complete and print this form and mail with check payable to Hospice Alliance Foundation. Mail to: Hospice Alliance, 10220 Prairie Ridge Blvd., Pleasant Prairie, WI 53158. For more information, call (262) 652-4400.

To pay by credit card, fill in the form above, click submit below and you will be automatically redirected to our donation page to complete your order with a payment.

To have your brick included in the Annual Service of Rememberance, all orders must be submitted 2 months prior to the date of service to allow time for creation and installation. For the 2025 Service, the latest order date is April 24, 2025. Any order received after this date will be included in the 2026 Annual Service of Rememberance.

Please verify that you are human*

Join us for our annual
Service of Remembrance and
Memorial Brick Dedication

Each June, friends and families are welcomed to our annual Service of Remembrance & Memorial Brick Dedication at the Kemper Center in Kenosha.To join us, please contact our Bereavement team at bereavement@hospicealliance.org or call (262) 652-4482 ext. 1211.