Name *

First Name

Last Name

Phone *

(###)

###

####

What rose variety I would like to adopt: *

Climbing Rose Trellis - $300

Caroline Testout, Portland's official rose - $400

Sally Holmes - $500

Please select one of the four options for text on the personalized plaque, in addition to the name and date: *

In Honor Of

In Memory Of

In Celebration Of

Donated By

Name as it should appear on the plaque: *

Dedication Name

First Name

Last Name

Preferred Date

MM

DD

YYYY