Send completed application & payment to: Storybook Island, P.O.

Box 9196, Rapid City, SD

Sponsor’s Name _______________________________________ Date _____________________

Address __________________________________________________________________________

Phone/Cell ___________________________ e-mail _______________________________________

The cost per brick is $50.00. Payment or Credit Card information must accompany the application. Please
make checks payable to Storybook Island. The bricks will be placed in designated brickyards in the park. You
may sponsor as many bricks as you like. If you would like more than two bricks, please include the
information on an attached sheet. There may be three lines on each brick with room for up to 14 total letters,
numbers or spaces on each line. Please print clearly and be sure to check the spelling. You will be notified
when and where the brick is placed. Thank you for supporting Storybook Island.

For Office Use - Brick# ___________ Area _________

For Office Use - Brick# ___________ Area _________

Signature ____________________________________________ (Person approving the spelling above)

Payment Options: Cash – Amount enclosed __________ Check – Amount Enclosed ____________

Credit Card: Visa Mastercard Discover

CC# __________________________________________ Exp Date ____________ V-Code _______
(3-digit #)
Name as it appears on card ___________________________________________________________
(Please print clearly)

Signature __________________________________________________________________________

02.11 CD
Brick Application

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