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 Hudson Valley NY Spring 2025
Event ID11846
Participant ID29739475
Participant NameKatie Broughal
Team NameWOI - Christine Pellegrino
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