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 Name2022 Syracuse Heart Walk
Event ID6419
Participant ID3096274
Participant NameKristin Thompson Henry
Team NameTeam Thompson Henry
Team ID

Mailing Information

Please send this completed form with checks to:American Heart Association | Four Gateway Center, 444 Liberty Ave, Suite 1300 | Pittsburgh, PA 15222