Donor Information

First Name
Last Name
Billing Address:
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 Eastern Connecticut Heart Walk
Event ID5176
Participant ID
Participant Name
Team NameCorinne's RX Walkers
Team ID563795

Mailing Information

Please send this completed form with checks to:American Heart Association Eastern Connecticut Heart Walk| 5 Brookside Dr | Wallingford, CT 06492