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 Name2025 Southern Tier Heart Walk
Event ID11525
Participant ID
Participant Name
Team NameAndrew R. Mancini Associates ,Inc
Team ID886026
Mailing Information
Please send this completed form with checks to:American Heart Association | Attn: Southern Tier Heart Walk | Four Gateway Center | 444 Liberty Ave, Ste 1300 | Pittsburgh, PA 15222