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 Central Iowa Heart Walk
Event ID6501
Participant ID19334400
Participant NameDylan Moore
Team NameThe Cup on 2nd
Team ID

Mailing Information

Please send this completed form with checks to:American Heart Association | 8805 Chambery Blvd. #300 PMB 126 | Johnston, IA 50131