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 Northeast PA Heart Walk
Event ID12608
Participant ID31296721
Participant NameNatalie Kotulski
Team NameGuided By Destiny
Team ID
Mailing Information
Please send this completed form with checks to:American Heart Association | Attn: NE PA Heart Walk | 4217 Park Place Court | Glen Allen, VA 23060