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 Name2025 Eastern Connecticut Heart Walk
Event ID12013
Participant ID24088267
Participant NameScott Selig
Team NameCharter Oak- Dayville
Team ID
Mailing Information
Please send this completed form with checks to:American Heart Association | Attn: Eastern CT Heart Walk | Eastern States-Accts Rec, PO Box 4002012 | Des Moines, IA 50340-2012