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 Name2024 Central Iowa Heart Walk
Event ID9949
Participant ID28394941
Participant NameTina Tran
Team NameThe Iowa Clinic Cardiovascular Services
Team ID
Mailing Information
Please send this completed form with checks to:American Heart Association | Attn: Central Iowa Heart Walk | 8805 Chambery Blvd #300 PMB 126 | Johnston, IA 50131