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 Winston-Salem Heart & Stroke Walk
Event ID6175
Participant ID
Participant Name
Team NameCycleBar Winston-Salem
Team ID636286

Mailing Information

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