Winnebago County - Angelfire
Winnebago County, Illinois
AMATEUR RADIO EMERGENCY SERVICE
ARES
Registration and Member Survey
Personal Information Date _________________ Call Sign: _______________
Name _____________________________ License Class: _______________
Address ___________________________ Home Phone: (___)-____-_____
City, Zip ___________________________ Work Phone: (___)-____-_____
E-Mail _____________________________ Cell Phone: (___)-____-_____
Which telephone number should be used to contact you for Emergency Alerts and Activations? ___________
May we contact you by e-mail regarding ARES information and activities? Yes No
Skills
(Please indicate with a check mark in each box, if you are experienced, willing to learn, and/or will to teach.)
↓ Experienced
↓ Willing to teach
↓ Willing to learn
( ( ( Operating for Public Service events, (e.g., runs, races, walk-a-thons, other special events, etc.)
( ( ( Participation in ARES or RACES Emergency Communications (including drills)
( ( ( Severe weather spotter - ( I have received NOAA – SKYWARN Training.
( ( ( Net Control – Traffic Net (e.g. Thurs night net)
( ( ( Net Control – Scheduled Nets, Events, Emergencies
( ( ( Formal Traffic Handling
( Communication system repairs (willing to repair damaged equipment)
( Other useful skills – Please list on the back of this form
Resources 160 80 40 20 15 10 6 2 220 440 Other
SSB (Home) ( ( ( ( ( ( ( ( ( ( ( _________________
CW (Home) ( ( ( ( ( ( ( ( ( ( ( _________________
Directional Antenna (Home) ( ( ( ( ( ( ( ( ( ( ( _________________
Packet (Home) ( ( ( ( ( ( ( ( ( ( ( _________________
FM Voice (Home) ( ( ( ( ( ( ( ( ( ( ( _________________
FM (Mobile) ( ( ( ( ( ( ( ( ( ( ( _________________
FM (Portable HT) ( ( ( ( ( ( ( ( ( ( ( _________________
Mobile/Portable D/F ( ( ( ( ( ( ( ( ( ( ( _________________
Cross-band repeat function ( ( ( ( ( ( ( ( ( ( ( _________________
Portable repeater ( ( ( ( ( ( ( ( ( ( ( _________________
Special Transportation:
( Boat Type___________ ( w/antenna, bands________________ ( Marine Radio
( Motorcycle ( w/antenna, bands________________
( Snowmobile ( w/antenna, bands________________
( ATV ( w/antenna, bands________________
( 4-wheel drive ( w/antenna, bands________________
( Trailer towing vehicle Indicate ball size and hitch class ______________________
Other Specialized Equipment you possess:
( Portable Packet ( 115v ( 12v ( Battery ( Cellular Phone
( Portable Computer ( 115v (12v ( Battery ( Citizens Band Radio
( Portable Printer ( 115v ( 12v ( Battery ( GPS Receiver
( 12v Power Supply __________ Amps ( Video Camcorder
( 12-115 Volt inverter _________ Watts
( 12v Portable Battery _________ Amp-hours
( Portable Generator ( 115v ________ Watts ( 220v ____________ Watts ( 12vdc ______amps
( Portable Lighting ( WX Radar Rec. ( Equipment to repair damaged commercial installations
Continued On Back of Page: →
Name ________________________________ Call Sign: ___________________
Which is the nearest major intersection to your home, (i.e., highways, roads, etc.)? ____________________________________ at ________________________________
Emergency Communications Training
Amateur Radio Emergency Communications Courses:
ARECC Level I, Date: _______ ARECC: Level II, Date: _______ ARECC: Level III Date: _______
Department of Homeland Security, Federal Emergency Management Agency Courses:
IS-100, Date: _______ IS-200, Date: _______ AS-700, Date: _______ IS-800, Date: _______
Other Courses: ______________________________________________________________________________
NOAA, National Weather Service, and SKYWARN Training:
Basic Date: ________ Location: _______________________________________________
Advanced: Date: ________ Location: _______________________________________________
Other: ______________________________________________________________________________________
Other EmComm Training Courses: __________________________________________________________________________________________________________________________________________________________________________
Are you willing to attend training? Yes No
What training would you like to be offered? __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Availability: Daytime Evening Best Time(s) Day(s) of the Week
( ( _______________ ___________________________
Second choice: ( ( _______________ ___________________________
When are you available for ARES response? ________________________________________________________________
Do you wish to become more involved in ARES? If so how? ___________________________________________________
I would like to become more acquainted with you, so would you tell me a bit about yourself?
Signiture: ___________________________________________________________ Date: _________________
Please download, print, complete and sign this forms. Then mail to me: John Cotner, KC9IED
525 Hemenway Place
South Beloit, IL 61080-1942
Thank you,
John Cotner, KC9IED
Winnebago County ARES EC, (Acting)
KC9IED@
815-389-3418
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