Montgomery County, Ohio Amateur Radio Emergency Service (ARES) Registration Form - FSD-98
* Required
Form Status
*
New
Change
Current Year 2021
Required
Membership Classification
*
Active - Level 1
Active - Level 2 (All 4 FEMA/NIMS ICS 100, 200, 700, 800 Courses Completed - Certs On File)
Active - Level 3 (Level 2 requirements plus ICS 300 & 400 Completed - Certs on File)
Reserve Pool
Required
Name (Last, First, MI)
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Mailing Address
*
Your answer
City, State, Zip Code+4
*
Your answer
Email Address
*
If no email enter "None"
Your answer
Alternate Email Address
Your answer
ARES ID # (If Known)
Your answer
Call Sign
*
Your answer
License Class
*
Novice
Technician
General
Advanced
Extra
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.
Your answer
Work Phone Number
*
Enter N/A for Not Applicable. Place a "P" after number if this is your primary contact number.
Your answer
Cell Phone Number
*
Enter N/A for Not Applicable. Place a "P" after number if this is your primary contact number.
Your answer
OPERATING EQUIPMENT CAPABILITY
Identify the communication modes that you have the capability to operate.
Voice
HF
*
Home
Mobile
Portable
Not Applicable
Required
VHF
*
Home
Mobile
Portable
Not Applicable
Required
UHF
*
Home
Mobile
Portable
Not Applicable
Required
Digital Mobile Radio (DMR)
*
Home
Mobile
Portable
Not Applicable
Required
D-STAR
*
Home
Mobile
Portable
Not Applicable
Required
Fusion
*
Home
Mobile
Portable
Not Applicable
Required
Echolink
*
Home
Mobile
Portable
Not Applicable
Required
Amateur Television (ATV)
*
Home
Mobile
Portable
Not Applicable
Required
Digital
Automatic Packet Reporting System (APRS)
*
Home
Mobile
Portable
Not Applicable
Required
CW
*
Home
Mobile
Portable
Not Applicable
Required
Narrow Band Emergency Messaging System (NBEMS/FLDIGI)
*
Home
Mobile
Portable
Not Applicable
Required
Packet
*
Home
Mobile
Portable
Not Applicable
Required
Pactor
*
Home
Mobile
Portable
Not Applicable
Required
RTTY
*
Home
Mobile
Portable
Not Applicable
Required
Winlink 2000
*
Home
Mobile
Portable
Not Applicable
Required
Do you have HF Emergency Power Capability at home?
*
Yes
No
Do you have VHF Emergency Power Capability at home?
*
Yes
No
What is your Emergency Callout Availability?
*
Day
Night
Both
Do you have any Disabilities that would prevent you from serving in the field?
*
Yes
No
If "Yes" to above question, can you serve as a Net Control Operator from your home?
Yes
No
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:
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
IS-300 - Intermediate ICS for Expanding Events
IS-400 - Advanced ICS for Command and General Staff, Complex Incidents
Other:
First Aid Training
Indicate Expiration Date in the "Other" field
First Aid
CPR
AED
Other:
Advanced Medical Training
Indicate Expiration Date in the "Other" field
EMT
EMT-I
EMT-P
Nurse
Doctor
Other:
SKYWARN Training
Indicate Training Date in the "Other" field
Basic
Advanced
Other:
SKYWARN ID Number
Your answer
C.E.R.T. Certified
Indicate Date completed in the "Other" field
Yes
No
Other:
Clear selection
Other Certifications / Training (Please Specify)
Your answer
Do you want to be included in the MOCOPT (Montgomery County Priority Traffic) Mailing List?
*
This notifies you of ARES / Skywarn Net Activiations
Yes
No
Provide Email &/or Cell Phone Email Address, cell phone carrier that you want the MOCOPT sent to.
Your answer
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:
Agency Affiliation (Check all that apply)
American Red Cross
Government
Fire Department
Law Enforcement
Medical
Salvation Army
Search & Rescue
Military
Other:
Are you registered in the ARRL's ARES Connect database? If not, please register at
arrl.volunteerhub.com/lp/oh
*
Yes
No
In signing the Montgomery County ARESĀ® 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
*
Your answer
Date
*
MM
/
DD
/
YYYY
MoCoARES FSD-98 (rev 1/19)
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