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 Madison Heart Walk
Event ID10696
Participant ID28673004
Participant NameClaudia Lopez
Team NameMGE Healthy Hearts
Team ID
Mailing Information
Please send this completed form with checks to:American Heart Association | Attn: Madison Heart Walk | 2850 Dairy Drive, Suite 130 | Madison, WI 53718