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 Greater Charlotte Heart Walk
Event ID12047
Participant ID30681285
Participant NameRuss Williams
Team NameWalkin' with Wiethoff
Team ID
Mailing Information
Please send this completed form with checks to:American Heart Association | Attn: Charlotte Heart Walk | 5445 77 Center Dr, Ste 60 | Charlotte, NC 28217