Donor Information

First Name
Last Name
Billing Address:
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 Name2020 Central Ohio Virtual Heart Walk
Event ID5293
Participant ID
Participant Name
Team NameHeartificial Intelligence
Team ID567156

Mailing Information

Please send this completed form with checks to:American Heart Associaion | 5455 North High Street | Columbus, OH 43214