Get Moving to End Polio

Name*

First NameLast Name

Email*

example@example.com

Phone Number*

Area CodePhone Number

Rotary Club (if applicable):

I'd like to volunteer for the following:*

Take on an 18 minute relay slotProvide event supportGive information to the publicAny/All of the above

I'd prefer to do my 18 minutes on:

A TreadmillA static bikeA rowing machineI don't mind

I can help/take part at the following times:*