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 Southeastern Oklahoma Heart and Stroke Walk
Event ID
6438
Participant ID
23986711
Participant Name
Lisa Frank
Team Name
Ardmore Clinic
Team ID
Mailing Information
Please send this completed form with checks to: