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
$120
$60
$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 Name2024 Eastern Connecticut Heart Walk
Event ID10713
Participant ID27494501
Participant NameTeam Captain
Team NameEastern CT AHA
Team ID
Mailing Information
Please send this completed form with checks to:American Heart Association | Attn: Eastern Connecticut Heart Walk | 4217 Park Place Court | Glen Allen, VA 23060