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 Ohio Heart Walk
Event ID10685
Participant ID13917312
Participant NameCorey Balogh
Team NameAvaap Columbus
Team ID
Mailing Information
Please send this completed form with checks to:American Heart Association | Attn: Central Ohio Heart Walk | 1650 Lake Shore Dr #350 | Columbus, OH 43204