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 Name2022 Southeastern Oklahoma Heart and Stroke Walk
Event ID6438
Participant ID21946407
Participant NameChelsea Hollenbeck
Team NameArdmore Clinic
Team ID

Mailing Information

Please send this completed form with checks to:American Heart Association | 3401 NW 63rd Street, Suite 510 | Oklahoma City, OK 73116