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 Name2020 Northeast Indiana Heart Walk Digital Experience
Event ID5207
Participant ID1604225
Participant NameJanice Bir
Team NameTeam Jody
Team ID
Mailing Information
Please send this completed form with checks to: