Polio Plus Society Form

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   Rotary District 5890

To:  The Membership


From:  District 5890 Polio Plus Committee


Subject:  My Personal Commitment


As a member of a District 5890 Rotary Club, I recognize my personal privilege to be able to share in Rotary’s effort to stamp out Polio worldwide.

I hereby commit, by signing below, to make a yearly donation of at least $100 to the Polio Plus program of The Rotary Foundation.

This I pledge to do each year until Polio is officially pronounced as eradicated from all mankind.  As such, I will be designated as a member of the “Polio Plus Society”.


Until the last child is immunized,

Polio is just a plane ride away

from me, my friends and my family.


Name & Signature


Club Name                                                              Date


Email Address


Provide a copy to your Club Foundation Chair AND Fax or email completed forms to Terry Ziegler, District 5890 Polio Plus Committee Chair, at Fax 713-748-2605, email bigzlumber@aol.com.  Questions?  Phone 713-748-1730