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 Winston-Salem Heart & Stroke Walk
Event ID7079
Participant ID23758890
Participant NameRobin Williams
Team NameWalkamolies
Team ID

Mailing Information

Please send this completed form with checks to:American Heart Association | 1818 Patterson Ave | Nashville, TN 37203