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 ID21544800
Participant NameMaria Carabantes
Team NameThe Dream Team
Team ID

Mailing Information

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