Your application form for membership of the Fellowship

First Name

Last Name

Birth Date *

Month Day Year

E-mail *

Where we can send our regular newsletter

Where were you living when you caught polio? *

During what year did you catch Polio? *

Just a rough idea of where you are living now? *

So we can add you to our world map of Polio Survivors

Would you like us to post you a printed and bound copy of our booklet for all GPs and Primary Carers - "Managing the Late Effects of Polio" This is free, including postage, whatever your home country

Yes, so my postal address is as below: No, but I would like you to send me one by email, please No

Please add your postal address here if you have selected a posted copy.

Your Postal Address

Membership of our Fellowship is completely free and does include an electronic bi-monthly newsletter sent to your email address.

However, if you would like to make a donation to support the work that we are doing for all polio survivors around the world, you are able to do so below.

My Donation

USD Please accept our grateful thanks on behalf of over 20 million polio survivors.

Payment Methods

Debit or Credit Card

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Please click one of the PayPal options to complete payment and submit the form.

Membership Information