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

Name:__________________________________________________________________

Address: _________________________________________________________________________________

__________________________________________________postal code: __________

Phone:_________________________

Annual Membership Fee: (Jan. to Dec.)

Please make cheque payable to Polio Regina Inc.
(If you require sponsorship for your fee, inform our membership chairman)
*official receipt for income tax will be mailed for donations over $10.

and mail to:
Polio Regina Inc.
825 McDonald St.
Regina, SK S4N 2X5

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