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 ID32373343
Participant NameHaley Notzen
Team NameUChicago Medicine NWI- Pulse Patrol
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