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 Grand Rapids Heart Walk
Event ID11034
Participant ID28632022
Participant NameKeri Dutkiewicz
Team NamePounce Pack
Team ID
Mailing Information
Please send this completed form with checks to:American Heart Association | Attn: Grand Rapids Heart Walk | 3940 Peninsular DR SE, Ste 180 | Grand Rapids, MI 49546