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 ID
Participant Name
Team NameL+M Urology
Team ID855803
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