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 Name2020 North Country VIRTUAL Heart Walk (MOVE WHERE YOU ARE)
Event ID4962
Participant ID
Participant Name
Team Name
Team ID

Mailing Information

Please send this completed form with checks to:2 Clintonn Square Suite 305 | Syracuse NY 13202