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 Central Kentucky Heart Walk
Event ID6538
Participant ID13829460
Participant NameShorus Minella
Team NameUKHC Pumped-Up Hearts
Team ID

Mailing Information

Please send this completed form with checks to:American Heart Association | 354 Waller Ave #110 | Lexington, KY 40504