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:
$1000
$500
$250
$120
$60
$35
Other Amount:
Please display my name on the participant's public donor wall as:
Please do not display my name on the donor wall.
Participant Information
Event Name2024 Central Kentucky Heart Walk
Event ID10075
Participant ID28471973
Participant NameJad Ballout
Team NameGill Heart Institute
Team ID
Mailing Information
Please send this completed form with checks to: