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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