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 Name2021 Guilford Heart & Stroke Walk
Event ID5653
Participant ID19899678
Participant NameMadhava Pally
Team NameSigma Nu's Community Garden in High Point
Team ID

Mailing Information

Please send this completed form with checks to:American Heart Association | 1589 Skeet Club Road, Suite 102-352 | High Point, NC 27265