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 Name2026 Southern Tier Heart Walk
Event ID12602
Participant ID
Participant Name
Team NameGuthrie Binghamton Pain Care
Team ID956346
Mailing Information
Please send this completed form with checks to:American Heart Association | Attn: Southern Tier Heart Walk | 444 Liberty Ave, Ste 1300 | Pittsburgh, PA 15222