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 Kentucky Heart Walk
Event ID6538
Participant ID21032720
Participant NameMary Beth Glowatz
Team NameCLARK Raising Hope
Team ID

Mailing Information

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