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 Midlands Heart Walk
Event ID6482
Participant ID22385285
Participant NameHeather Long
Team NameWe've Got Heart
Team ID

Mailing Information

Please send this completed form with checks to:American Heart Association | 701 Gervais Street, Suite 150 PMB#150 | Columbia, SC 29201