If you'd like to join us come to a meeting or print this form:

Name:__________________________________________________________________

[ ] Active -if you had polio

[ ]Associate

[ ] New

[ ]Renewal

Address: _________________________________________________________________________________

__________________________________________________Postal code: __________

Phone:__________________________    Email: _______________________________

Annual Membership Fee: (Jan. to Dec.)

$10 Single; $15 Family	$________________
My donation to Polio Regina	$________________
Total:	$________________

Please make cheque payable to Polio Regina Inc.

Mail Memberships and Donations to:
Polio Regina Inc.
78 Petersmeyer St.
Regina SK  S4R 7P7

OR send bank e-transfer to our email address:  polioregina@outlook.com

Official receipt for income tax will be mailed.

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