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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?
Are you a current Rotarian or Rotaractor?
Rotary or Rotaract Club Name
Are you or have you ever been a member of any of these Rotary programs?
TRF Grant Scholar
Group Study Exchange
Have you participated in an NID/SID
No-but would like to
About Yourself - optional
Other Rotary Offices
District Foundation Chair
Zone End Polio Coordinator
District Polio Chair
District International Service Chair
What would you like others in our Rotary Action Group to know about you?
Your Membership Information
Additional fields for Polio Ambassador Application
Are any family members a polio survivor?
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?