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 NameLong Island Leaders of Impact Fall 2025
Event ID12662
Participant ID917412
Participant Name
Team Name
Team ID
Mailing Information
Please send this completed form with checks to:American Heart Association | Attn: Long Island Leaders | 4217 Park Place Ct | Glen Allen, VA 23060