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:
Other Amount:
Please display my name on the participant's public donor wall as:

Participant Information

Event Name2024 Grand Rapids Heart Walk
Event ID11034
Participant ID28595212
Participant NameChristina Withers
Team NameHeart & Spectacular
Team ID

Mailing Information

Please send this completed form with checks to:American Heart Association | Attn: Grand Rapids Heart Walk | 3940 Peninsular DR SE, Ste 180 | Grand Rapids, MI 49546