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 Name31st Annual Bert Blain Memorial Heart Walk
Event ID11073
Participant ID28526731
Participant NameKaren Larson
Team NameBaker Tilly
Team ID
Mailing Information
Please send this completed form with checks to:American Heart Association | Attn: Bert Blain Memorial Heart Walk | 2850 Dairy Dr, Ste #130 | Madison, WI 53718