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 Southern Tier Heart Walk
Event ID9819
Participant ID18461114
Participant NameKelton Raymond
Team NameLub Dub...The Beat Goes On
Team ID
Mailing Information
Please send this completed form with checks to:American Heart Association | Attn: Southern Tier Heart Walk | 444 Liberty Ave, Suite 1300 | Pittsburgh, PA 15222