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 Wayne County Heart Walk
Event ID13173
Participant ID22095226
Participant NameTerence Rhodes
Team NameWestern Reserve Group
Team ID
Mailing Information
Please send this completed form with checks to:American Heart Association | Attn: Wayne Heart Walk | 1375 E 9th St, Ste 600 | Cleveland, OH 44114