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 Tri-County Heart Walk
Event ID6441
Participant ID24061725
Participant NameDiane O'Connell
Team NameCardiology
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