ClayARES Membership Application

ClayARES Membership Application

Application to join the Clay County Amateur Radio Emergency Service
County*
Date Submitted*

MonthDayYear
Date
Name*

First NameLast Name
Call Sign*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Amateur Radio License Class*

AdvancedAmateur ExtraGeneralNoviceTechnician
Email*
example@example.com
Home Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Mobile Phone Number*
Please enter a valid phone number.
Mobile Phone Provider
Are you a member of any other local Amateur Radio Clubs / Organizations?

OPARCNOFARSDuval ARESSt Johns County ARESNassau County ARESOther
Can your home station be operated without commercial power?*

YesNo
Available Operating Modes (Select all that apply)*

VHF FMVHF SSBVHF CWVHF Digital (Packet, etc)VHF MobileUHF FMUHF SSBUHF CWUHF Digital (Packet, etc)UHF MobileHF SSBHF CWHF Digital (Packet, PKK, FT8, etc)HF Mobile
Are you available for special events?*

YesNo
Are you available to deploy to local shelters? (some training is required)*

YesNo
Are you available to deploy within the Crown District (Clay, Duval, Nassau, Putnam, St. Johns)?*

YesNo
Are you available to deploy outside the Crown District?*

YesNo
Are you a CERT Member?*

YesNo
Have you completed any of the following ICS Courses?*

IS-100 - Intro to ICSIS-200 - ICS for Single Resource and Initial Action IncidentsIS-700 - Intro to NIMSIS-800 - Into to National Response NetworkNone yet
Please provide any other pertinent details
Please verify that you are human*
Should be Empty: