Donor Information

First Name
Last Name
Billing Address:
City:
State:
Zip:
Phone Number:
Email Address:

Donation Amount

I would like to make a donation in the amount of:
Other Amount:
Please display my name on the participant's public donor wall as:

Participant Information

Event Name2020 Heart Mini
Event ID4985
Participant ID3091720
Participant NameScott Thomas
Team NameRun 4 Your Health
Team ID

Mailing Information

Please send this completed form with checks to:5211 Madison Road, Cincinnati, OH 45227