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 Name2026 Corridor Heart Walk
Event ID12617
Participant ID2096417
Participant NameScott Hansche
Team NameTHE SLAM COLLABORATIVE
Team ID
Mailing Information
Please send this completed form with checks to:American Heart Association | Attn: Corridor Heart Walk | 1035 N Center Point Rd, Ste B | Hiawatha, IA 52233