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 TriCounty Heart Walk
Event ID6431
Participant ID23851398
Participant NameWallette Amos
Team NameMercy Health Youngstown Leaders
Team ID

Mailing Information

Please send this completed form with checks to:American Heart Association | 1575 Corporate Woods Parkway Ste. 150 | Uniontown, OH 44685