Application for Polio Ambassador Program
Refer to our website for full program details.
You must also be a PSA member - if you have not completed that form, please return to the website and enter the same email address on that form.
Sign in to Google
to save your progress.
* Indicates required question
Rotary District (numbers only)
Member of Rotary since (year)
Never submit passwords through Google Forms.
This form was created inside of Rotary Polio Survivors & Associates.