Donor Information

First Name
Last Name
Billing Address:
City:
State:
Zip:
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 Name2022 Northwest Ohio Heart Walk
Event ID6384
Participant ID23470250
Participant NameSusan Garza
Team NameClinical has Heart
Team ID

Mailing Information

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