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 New Mexico Heart Walk & 5K Run
Event ID11043
Participant ID28647537
Participant NameJames Dickey
Team NameDelta Dental of New Mexico
Team ID
Mailing Information
Please send this completed form with checks to:American Heart Association | Attn: New Mexico Walk/Run | 12345 N Lamar Blvd, Ste 200 | Austin, TX 78753