Bricks Order Form


                              ALUMNI/MEMORIAL BRICKS


Please place your order by the three examples below only.    PLEASE PRINT.


Alumni                            In Memory of                       

 Jane Wilson                   John Smith    

Class of 1955                Class of 1930


 Teacher/VP/ Principal / Counselor

John Smith

1960 to 1980


   4 lines per brick only   (only 21  characters per line - 18 recommended 


First line __________________________________________________


Name ____________________________________________________




Graduation Year  _______________


Please print and send this application along with a check or money order for $35.00 to Wilby High School Alumni Association, PO Box 4503, Waterbury, CT 06704   Please provide an address, phone, or e-mail so we can notifly you when the bricks arrive.

Bricks are ivory with emerald green fill.