Polio Plus Society Sign Up Form

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Complete this form to sign up for the Polio Plus Society

Email *

Your First Name *

Your Last Name *

Your Club *

Your Phone Number *

I pledge to contribute at least $100 each year until the World Health Organization certifies that Polio has been fully eradicated and the world is polio-free. I do this because…….UNTIL THE LAST CHILD IS IMMUNIZED AND THE WORLD IS CERTIFIED POLIO-FREE, EVERY CHILD IS AT RISK.

Yes

Polio Plus Society membership certificate and pin will be mailed to your club president for presentation at a club meeting. We want you to be properly recognized for your commitment to polio eradication. Do you have any additional comments for us? THANK YOU for your support!!

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