Montgomery County, Ohio Amateur Radio Emergency Service (ARES) Registration Form - FSD-98
Form Status *
Required
Membership Classification *
Required
Name (Last, First, MI) *
Date of Birth *
MM
/
DD
/
YYYY
Mailing Address *
City, State, Zip Code+4 *
Email Address *
If no email enter "None"
Alternate Email Address
ARES ID # (If Known)
Call Sign *
License Class *
Required
Date First Licensed *
MM
/
DD
/
YYYY
License Effective Date *
MM
/
DD
/
YYYY
License Expiration Date *
MM
/
DD
/
YYYY
Home Phone Number *
Enter N/A for Not Applicable. Place a "P" after number if this is your primary contact number.
Work Phone Number *
Enter N/A for Not Applicable. Place a "P" after number if this is your primary contact number.
Cell Phone Number *
Enter N/A for Not Applicable. Place a "P" after number if this is your primary contact number.
OPERATING EQUIPMENT CAPABILITY
Identify the communication modes that you have the capability to operate.
Voice
HF *
Required
VHF *
Required
UHF *
Required
Digital Mobile Radio (DMR) *
Required
D-STAR *
Required
Fusion *
Required
Echolink *
Required
Amateur Television (ATV) *
Required
Digital
Automatic Packet Reporting System (APRS) *
Required
CW *
Required
Narrow Band Emergency Messaging System (NBEMS/FLDIGI) *
Required
Packet *
Required
Pactor *
Required
RTTY *
Required
Winlink 2000 *
Required
Do you have HF Emergency Power Capability at home? *
Do you have VHF Emergency Power Capability at home? *
What is your Emergency Callout Availability? *
Do you have any Disabilities that would prevent you from serving in the field? *
If "Yes" to above question, can you serve as a Net Control Operator from your home?
CERTIFICATION / TRAINING
Identify any emergency communication, disaster management, training or certifications you have. Please submit copies of all certifications to mocoares@mocoares.org.
ARECC (Amateur Radio Emergency Communication Course)
Indicate Certification Dates in the "Other" field
FEMA Courses Taken
Indicate Certification Dates in the "Other" field
First Aid Training
Indicate Expiration Date in the "Other" field
Advanced Medical Training
Indicate Expiration Date in the "Other" field
SKYWARN Training
Indicate Training Date in the "Other" field
SKYWARN ID Number
C.E.R.T. Certified
Indicate Date completed in the "Other" field
Clear selection
Other Certifications / Training (Please Specify)
Do you want to be included in the MOCOPT (Montgomery County Priority Traffic) Mailing List? *
This notifies you of ARES / Skywarn Net Activiations
Provide Email &/or Cell Phone Email Address, cell phone carrier that you want the MOCOPT sent to.
Club Affiliations (Check all that apply)
Agency Affiliation (Check all that apply)
Are you registered in the ARRL's ARES Connect database? If not, please register at arrl.volunteerhub.com/lp/oh *
In signing the Montgomery County ARES® Application, it is understood that I must hold a valid Amateur Radio Operator License, possess a serious interest in providing emergency communications (community service) and committed to regular participation in meetings, nets, trainings, drills and community service events that will constitute the core group of prepared & ready to respond personnel.
Signature *
Date *
MM
/
DD
/
YYYY
MoCoARES FSD-98 (rev 1/19)
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms