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 Metro Chicago Heart Walk
Event ID10702
Participant ID28531712
Participant NameMaili Dellinger
Team NameImmunizations 3
Team ID
Mailing Information
Please send this completed form with checks to:American Heart Association | Attn: Metro Chicago Heart Walk | 300 S Riverside Plaza, Ste 1200 | Chicago, IL, 60606