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 Northwest Indiana Heart Walk
Event ID13196
Participant ID2167629
Participant NameAmy Tannish
Team NameThe Debriders
Team ID
Mailing Information
Please send this completed form with checks to:American Heart Association | Attn: NW Indiana Heart Walk | 8720 Castle Creek Pkwy E Dr, Ste 100 | Indianapolis, IN 46250