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* 1. Thank you for your interest in the Rotary Action Group (RAG) for refugees, forced displacement, and migration. To become a member, please fill this form. Membership is currently free, but we may decide to adopt a small membership fee in the future,  probably $25 per year, as done by several other RAGs to cover administrative costs. Please provide us with basic information to be able to contact you, as well as an indication of the reasons why you are interested in membership and how you would like to contribute to the RAG.

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* 2. Title (Mr., Ms., Mrs., Dr., etc.)

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* 3. First name

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* 4. Last name

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* 5. Gender

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* 6. Date of birth (DD/MM/YEAR) - OPTIONAL

Date

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* 7. Are you a Rotarian, Rotaractor, or Peace Fellow? Please indicate all that apply.

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* 8. If you are a Rotarian or Rotaractor, please indicate the name of your club and your personal Rotary International ID number if you know it

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* 9. In which country is your club located? If you know the district number of your club, please provide it as well. If you are not a member of a Rotary club, please provide your country of residence. 

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* 10. Email

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* 11. Preferred phone number

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* 12. Alternate phone (if applicable)

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* 13. Preferred mailing address (not an email address - a  mailing address) - OPTIONAL

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* 14. Please indicate if the address is residence, business, or other

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* 15. Job title if currently employed

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* 16. Name of business or organization

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* 17. Classification (type of job/profession)

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* 18. Could you tell us briefly how you heard about us?

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* 19. Please tell us about yourself (short bio)

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* 20. Are you interested in one or more service activities in particular that would be beneficial to refugees and IDPs? If so, please explain?

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* 21. Any comments on suggestion on priorities for a potential RAG on IDPs and refugees? Thank you for completing this brief survey and we will be in touch.

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