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:
Other Amount:
Please display my name on the participant's public donor wall as:

Participant Information

Event Name2024 Long Island Heart Walk
Event ID10711
Participant ID
Participant Name
Team NameTeam Genova
Team ID835379

Mailing Information

Please send this completed form with checks to:American Heart Association | Attn: Long Island Heart Walk | 145 Pinelawn Road, Suite 240N | Melville, NY 11747