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 Fairbanks Heart Walk
Event ID12645
Participant ID3978230
Participant NameDerek Miller
Team NameCEM Heartbeat Hotel
Team ID
Mailing Information
Please send this completed form with checks to:American Heart Association | Attn: Fairbanks Heart Walk | 4380 S Macadam Ave, Ste 480 | Portland, OR 97239