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 Madison Heart Walk
Event ID12116
Participant ID30757862
Participant NameSamantha Jappinen
Team NameUWHC School of DMS
Team ID
Mailing Information
Please send this completed form with checks to:American Heart Association | Attn: Madison Heart Walk | 2850 Dairy Dr, Ste 130 | Madison, WI 53718