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 Name
2024 Oregon and SW Washington Heart & Stroke Walk
Event ID
9944
Participant ID
19519407
Participant Name
Deb Strom
Team Name
Home and Community Hearts in Motion
Team ID
Mailing Information
Please send this completed form with checks to: