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 NamePalm Beach Woman of Impact - Spring 2026
Event ID12886
Participant ID31492683
Participant NameJunnell Hughes
Team NameJanina Holland Simmonds
Team ID
Mailing Information
Please send this completed form with checks to:American Heart Association | Attn: Palm Beach WOI | 2300 Centrepark West Dr | West Palm Beach, FL 33409