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 Dutchess-Ulster Heart Walk
Event ID6420
Participant ID
Participant Name
Team NameTompkins Mahopac Bank Team
Team ID690180

Mailing Information

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