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 Name2023 Tuscaloosa Heart Walk
Event ID8034
Participant ID
Participant Name
Team NamePatient Liaison, Risk, and Safety Departments
Team ID766650
Mailing Information
Please send this completed form with checks to: