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 Northeast Georgia Heart Walk
Event ID10898
Participant ID28503940
Participant NameKimberly Miller
Team NameBEAT IT!
Team ID
Mailing Information
Please send this completed form with checks to:American Heart Association | Attn: NE GW Heart Walk | 519 E 4th St | Chattanooga, TN 37403