2006 FRRL Emergency Survey


First Name:
Last Name:
License Class:

Address

Line 1
Line 2
City
State
Zip

Contacts

Home Phone:
Work Phone:
Cell Phone:
Primary Email:
Secondary Email:
Pager:

Memberships

Check any organization to which you belong:
Kane Co. OEM Kane Co. ARES SATERN
Kendall Co. EMA Kendall Co. ARES FRRL
ARRL
Enter any other amateur radio or emergency organization to which you belong:

Stations and Equipment

Is your equipment insured other than under a home owner's policy?

Home Station

Check off any bands and modes that you can operate and list any modes not accounted for:
MODE HF* VHF UHF
Data
Packet
CW
SSB
FM
Other

* - List Primary Bands

Do you have back up power? Generator Batteries

Mobile Station

Check off any bands and modes that you can operate and list any modes not accounted for:
MODE HF* VHF UHF
Data
Packet
CW
SSB
FM
Other

* - List Primary Bands

What kind of vehicle do you have?

Portable Station

Check off any bands and modes that you can operate and list any modes not accounted for:
MODE HF* VHF UHF
Data
Packet
CW
SSB
FM
Other

* - List Primary Bands

Can you use standard batteries?

Other Equipment

Do you have any equipment that you would loan out in an emergency? List/Describe:

Do you have any other equipment that you would use in an emergency? List/Describe:

Do you have a "Go Bag"? If so, describe it:

Deployment

Would you be willing/able to deploy for an emergency? Where are you willing to deploy to?

How long are you willing to deploy for?

Privacy

Can the data on this form be shared with Kane Co. ARES?

SUBMIT