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 Central Iowa Heart Walk
Event ID12620
Participant ID
Participant Name
Team NameClub Pilates Des Moines
Team ID960027
Mailing Information
Please send this completed form with checks to:American Heart Association | Attn: Central IA Heart Walk | 9203 Northpark Dr | Johnston, IA 50131