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2. Fill out and submit the form below. Upon receipt, we will notify you and confirm the information. Payment can be made in person with a check made payable to JCPRD and dropped off or mailed to 7900 Renner Road, Shawnee Mission, KS 66219. Attention: Cindy Lawrence PGC. Payment can also be made by phone with a Visa, Mastercard or Discover.
4. First and Last Name*
5. Date
   Date
7. Address*
9. City*
10. State*
11. Zip Code*
13. Email Address*
14. Phone #*
16. In memory of: (if applicable)
17. Relationship:
19. Park Location: list park plus detailed location*
21. Memorial Nameplate

    1. $500 Contribution

    Includes a bronze nameplate with your loved ones' name installed on our "In Memory Of" plaque located in Antioch Park, Heritage Park, Shawnee Mission Park or Tomahawk Hills Golf Course.
23. Please choose how you would like your remaining contribution to be used:

    1. Rose Bush at Helen S. Cuddy Memorial Rose Garden at Antioch Park
    2. Tree to be planted in same park name plate will be located
25. Contour Bench and Bench Plaque*

    1. $3000

    Donor's purchase includes a contour bench (with backrest) made of resin wood slats. This bench will be placed in the park of your choice. The location within the park can be requested but will have to be approved by the park manager. A bronze plaque will be installed on the backrest of the bench. *Bench and plaque not available in Meadowbrook Park
27. Memorial Panel at Meadowbrook Park

    1. $3000 Contribution

    Your purchase includes engraving of your loved one's name, birth year and death year on a panel located on the Memorial Wall at Meadowbrook Park.
29. Text for bench plaque
    Up to 45 characters per line, includes spaces. 3 line maximum. If listing dates, only birth year and death year allowed (i.e. 1900-1999)
31. Text for Panel at Meadowbrook Park
    Name, birth year - death year (i.e. John Son Parks 1900-2000)
33. Text for name plate for "In Memory Of" Plaque
    Maximum of 30 characters includes spaces, name only.
35. If you would like an acknowledgement email sent to someone please list their email below
36. Relationship to person receiving acknowledgement
Leave This Blank:


38. 1. Receive an email copy of this form.
39. Email address

    This field is not part of the form submission.

40. Submit

* indicates a required field