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 ID
Participant Name
Team NameCommunity Walkers
Team ID756992
Mailing Information
Please send this completed form with checks to:American Heart Association | 701 Gervais Street, Suite 150, PMB#150 | Columbia, SC 29201