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:
$1000
$500
$250
$120
$60
$35
Other Amount:
Please display my name on the participant's public donor wall as:
Please do not display my name on the donor wall.
Participant Information
Event Name2023 Midlands Heart Walk
Event ID7933
Participant ID22461210
Participant NameNicole Hendricks
Team NameEncompass Health Columbia Heart and Sole
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