Join – Polio Survivors Action Group

Join Polio Survivors Rotary Action Group

PS - you don't have to be a polio survivor to join!

Name
Username*
First Name
Last Name
Nickname
Contact Info
E-mail*
About Yourself
To better report on our membership to Rotary International, we need to know some things about your affiliation with Rotary
Are you a polio survivor?*
- Yes
- No
Are you a current Rotarian or Rotaractor?*
- Yes-Rotarian
- Yes-Rotaract
- No
Rotary District*
Rotary or Rotaract Club Name
Are you or have you ever been a member of any of these Rotary programs?
- Rotaract
- Interact
- Peace Fellow
- TRF Grant Scholar
- VTT
- Group Study Exchange
- TRF Cadre
Have you participated in an NID/SID
- No
- No-but would like to
- Yes-India
- Yes-Nigeria
- Yes-Other Country
About Yourself – optional
Other Rotary Offices
- District Governor
- District Foundation Chair
- Zone End Polio Coordinator
- District Polio Chair
- District International Service Chair
Biographical Info What would you like others in our Rotary Action Group to know about you?
Website
Your Membership Information
Additional fields for Polio Ambassador Application
Are any family members a polio survivor?
- No
- parent
- grandparent
- sibling
- aunt/uncle
- cousin
- other
Why are you interested in being a Ambassador for Polio Survivors?
Have you participated in any of the following?
- Local Polio Survivor group
- Rotary International Grant
- Vocational Training Team
- Polio Immunization Days (NID SID or similar)
Describe your involvement in any of the above
If not described above, what have you already done in your District or in Rotary to promote Polio Survivors or other physical disabilities?
Other skills you can provide as a Ambassador?
Is there someone from your Rotary District that we can contact to provide a recommendation for you?

Please check your SPAM or Junk folder for the confirmation message – some people have reported the email has gone astray.

Join Polio Survivors Rotary Action Group

PS - you don't have to be a polio survivor to join!

Name

Contact Info

About Yourself

About Yourself – optional

Your Membership Information

Additional fields for Polio Ambassador Application