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 Name2025 Central Ohio Heart Walk
Event ID12008
Participant ID1994839
Participant NameTrudi Souslin
Team NameThe cardioversion team
Team ID
Mailing Information
Please send this completed form with checks to:American Heart Association | Attn: Central Ohio Heart Walk | 1650 Lake Shore Dr, Ste 350 | Columbus, OH 43204