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 Name
2024 Washtenaw County Heart and Stroke Walk & 5K
Event ID
10314
Participant ID
28371203
Participant Name
Mara and Andrew Moss
Team Name
Erik's Kinetic Group (Team EKG)
Team ID
Mailing Information
Please send this completed form with checks to: