Polio Plus Society Pledge Form  
As a supporter of Polio Eradication, Rotary’s Number One Priority, I wish to participate in the Countdown to History as a member of the Polio Plus Society of District 5000.

I pledge to help Rotary make history by contributing $100 or more each and every year until the World Health Organization certifies that the Wild Polio Virus has been fully eradicated from the world.

This is my commitment to fulfill the promise Rotary made to immunize all the children of the world.

Society members will receive a PolioPlus Society membership pin, certificate and an End Polio Now bracelet... and your contribution qualifies for Paul Harris Recognition Points credit.

 Submit this form and complete your contribution commitment in one of two ways:
1. Contribute with your credit card online at: https://www.endpolio.org/donate.
2. Make out a check for $100 or more to The Rotary Foundation, with "Polio Plus" in the Memo section and submit to your Rotary Clubs Foundation Chair.

All donations will be matched 2 to 1 by the Bill and Melinda Gates Foundation.

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Name *
Best email address *
Address: Street *
City *
State *
Zip Code *
Phone *
Rotary ID #
Club Name: RC of
Rotary Club #
I hereby commit to making an annual donation to the Polio Plus Fund of The Rotary Foundation as follows (select one): *
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