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 NameTriangle Woman of Impact - Spring 2026
Event ID13003
Participant ID13003
Participant Name
Team Name
Team ID
Mailing Information
Please send this completed form with checks to:American Heart Association | Attn: Triangle WOI | 5001 S Miami Blvd Ste 300 | Durham, NC 27703