Montgomery County, Ohio Amateur Radio Emergency Service (ARES) Registration Form

Membership Classification

Active
Provisional
Reserve Pool

This is a required question

Name (Last, First, MI)

This is a required question

Mailing Address

This is a required question

City, State, Zip Code+4

This is a required question

Email Address

If no email enter "None"

This is a required question

Alternate Email Address

This is a required question

ARES ID # (If Known)

This is a required question

Call Sign

This is a required question

License Effective Date

License Expiration Date

Home Phone Number

Enter N/A for Not Applicable. Place a "P" after number if this is your primary contact number.

This is a required question

Work Phone Number

Enter N/A for Not Applicable. Place a "P" after number if this is your primary contact number.

This is a required question

Cell Phone Number

Enter N/A for Not Applicable. Place a "P" after number if this is your primary contact number.

This is a required question

OPERATING EQUIPMENT CAPABILITY

Identify the communication modes that you have the capability to operate.

Home
Mobile
Portable
Not Applicable

This is a required question

VHF

Home
Mobile
Portable
Not Applicable

This is a required question

UHF

Home
Mobile
Portable
Not Applicable

This is a required question

DSTAR

Home
Mobile
Portable
Not Applicable

This is a required question

Echolink

Home
Mobile
Portable
Not Applicable

This is a required question

Amateur Television (ATV)

Home
Mobile
Portable
Not Applicable

This is a required question

Automatic Packet Reporting System (APRS)

Home
Mobile
Portable
Not Applicable

This is a required question

Home
Mobile
Portable
Not Applicable

This is a required question

Narrow Band Emergency Messaging System (NBEMS/FLDIGI)

Home
Mobile
Portable
Not Applicable

This is a required question

Packet

Home
Mobile
Portable
Not Applicable

This is a required question

Pactor

Home
Mobile
Portable
Not Applicable

This is a required question

RTTY

Home
Mobile
Portable
Not Applicable

This is a required question

Winlink 2000

Home
Mobile
Portable
Not Applicable

This is a required question

Do you have HF Emergency Power Capability at home?

This is a required question

Do you have VHF Emergency Power Capability at home?

This is a required question

What is your Emergency Callout Availability?

Day
Night
Both

This is a required question

Do you have any Disabilities that would prevent you from serving in the field?

This is a required question

If "Yes" to above question, can you serve as a Net Control Operator from your home?

This is a required question

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

EC-001 - Introduction to Emergency Communications (formerly Level 1)
EC-002 - Introduction to Emergency Communications - Level 2 (discontinued)
EC-003 - Introduction to Emergency Communications - Level 3 (discontinued)
EC-016 - Public Service & Emergency Communications Mgmt for Radio Amateurs
Other:

This is a required question

FEMA Courses Taken

Indicate Certification Dates in the "Other" field

IS-100 - Intro to the Incident Command System
IS-200 - Single Resources & Initial Action Incidents
IS-700 - National Incident Management System
IS-800 - National Response Framework
IS-802 - Emergency Support Function (ESF) #2 Communications
Other:

This is a required question

First Aid Training

Indicate Expiration Date in the "Other" field

First Aid
CPR
AED
Other:

This is a required question

SKYWARN Training

Indicate Training Date in the "Other" field

Basic
Advanced
Other:

This is a required question

SKYWARN ID Number

This is a required question

C.E.R.T. Certified

Indicate Date completed in the "Other" field

Yes
No
Other:

This is a required question

Other Certifications / Training (Please Specify)

This is a required question

Do you want to be included in the MOCOPT (Montgomery County Priority Traffic) Mailing List?

This notifies you of ARES / Skywarn Net Activiations

This is a required question

Provide Email &/or Cell Phone Email Address, cell phone carrier that you want the MOCOPT sent to.

This is a required question

Club Affiliations (Check all that apply)

American Radio Relay League
Centerville Amateur Radio Society
Dayton Amateur Radio Association
Germantown Amateur Radio Society
Huber Heights Amateur Radio Club
Mound Amateur Radio Association
Mont. Co. Emg. Communication Team
West Central Ohio Amateur Radio Assn
Other:

This is a required question

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.

Montgomery County, Ohio Amateur Radio Emergency Service (ARES) Registration Form - FSD-98

OPERATING EQUIPMENT CAPABILITY

Voice

Digital

CERTIFICATION / TRAINING

MoCoARES FSD-98 (rev 02/14)