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 Syracuse Heart Walk
Event ID11470
Participant ID28868244
Participant NameMaarten Jacobs
Team NameAllyn Family Foundation
Team ID
Mailing Information
Please send this completed form with checks to:American Heart Association | Attn: Syracuse Heart Walk | Four Gateway Center444 Liberty Ave, Ste 1300 | Pittsburgh, PA 15222