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:
$250
$150
$75
$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 NamePittsburgh Leaders of Impact Fall 2025
Event ID12503
Participant ID30758118
Participant NameTodd Fleming
Team NameTodd Fleming
Team ID
Mailing Information
Please send this completed form with checks to: