Your application form for membership of the Fellowship

Membership Information
First Name
Last Name
Birth Date

MonthDayYear
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
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

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

Debit or Credit Card

Choose from one of the PayPal options to make your payment.

Membership Information