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 Stark County Heart Walk
Event ID12020
Participant ID28534508
Participant NameDiane Weisburn
Team NameSteel Savvy Sales
Team ID
Mailing Information
Please send this completed form with checks to:American Heart Association | Attn: Stark Heart Walk | 1575 Corporate Woods Pkwy, Ste 150 | Uniontown, OH 44685