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:
$1000
$500
$250
$120
$60
$35
Other Amount:
Please display my name on the participant's public donor wall as:
Please do not display my name on the donor wall.
Participant Information
Event Name
2022 Lake & Geauga Counties Heart Walk
Event ID
6403
Participant ID
1950360
Participant Name
Maria Strickland
Team Name
PUMC Rose Window Walkers
Team ID
Mailing Information
Please send this completed form with checks to: