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
$100
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 NameWoman of Impact Rochester NY Spring 2024
Event ID10444
Participant ID10444
Participant Name
Team Name
Team ID
Mailing Information
Please send this completed form with checks to:American Heart Association | Four Gateway Center, 444 Liberty Ave Suite 1300 | Pittsburgh, PA 15222