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 Ashtabula County Heart Walk
Event ID12019
Participant ID
Participant Name
Team NameCleveland Dental Institute Team
Team ID892787
Mailing Information
Please send this completed form with checks to:American Heart Association | Attn: Ashtabula County Heart Walk | 1375 E 9th St, Ste 600 | Cleveland, OH 44114