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:
$1000
$500
$250
$120
$60
$35
Other Amount:
Please display my name on the participant's public donor wall as:
Please do not display my name on the donor wall.
Participant Information
Event Name
2023 Southern Tier Heart Walk
Event ID
8043
Participant ID
2268071
Participant Name
Amy Skiba
Team Name
Walk it like its hot!
Team ID
Mailing Information
Please send this completed form with checks to: