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 Alaska Heart Run and Walk
Event ID10720
Participant ID
Participant Name
Team NamePacemakers of Prov Cardiac rehab and friends
Team ID850334
Mailing Information
Please send this completed form with checks to:American Heart Association | Attn: Alaska Heart Run | 4380 S Macadam Ave, Ste 480 | Portland, OR 97239