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 Oregon & SW Washington Heart and Stroke Walk Digital Experience
Event ID5700
Participant ID21039019
Participant NameSam Reid
Team NameMountain View HS Team
Team ID

Mailing Information

Please send this completed form with checks to:4380 SW Macadam Ave #480 | Portland, OR 97239