This Subscription Form is for use by subscribers from OUTSIDE the continental United States.  If you live in the United States please use the USA SUBSCRIPTION FORM and follow the directions provided.

SECTION ONE has two requirements:  Your name and your email address.  The rest is optional.
SECTION TWO, while helpful to polio/post-polio research, is strictly optional.  Your privacy will be respected.
SECTION THREE is for professionals interested in polio/post-polio syndrome.

When we receive your subscription we will immediately put you on our email list and you will receive a link via email beginning with the next issue of the Polio Post News.  You are always welcome to contact us via email anytime you have questions or would like some information.  We would love to hear from you.  YOU, after all, are why we are here.

Carolyn Raville, President
North Central Florida Post-Polio Support Group
International Subscription Form

SECTION ONE

Information
Name *

First

Last
Email *
Address

Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
How did you hear about us?
Are you a support group member?
 Yes 
 No 
If so, what is the name of your group and where is it located?

SECTION TWO

The questions in this section are optional, but your response will help us gain a better understanding of post-polio syndrome. This information is confidential and will not be linked to your name.
When did you first contract polio?
We would like to hear your comments (or updates) on your particular disability, problems with PPS, etc.

SECTION THREE

(This Section is for Healthcare Professionals and Support Group use.)
Is the address above your personal or professional address?
 Personal 
 Professional 
Are you...
 ...a MEDICAL PROFESSIONAL (Physician, Nurse, Clinic, etc.) 
 ...a HEALTHCARE PROFESSIONAL (Physical Therapy, Orthotics, etc.) 
 ...a SUPPLIER (Medicare supplier, Equipment supplier, etc.) 
 ...part of a SUPPORT GROUP 
 ...OTHER 
What is your Title or Position?
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