Georgia Baptist Disaster Relief Communications

Volunteer Information Form

Please complete the information requested below 

First Name  Last Name

Amateur Call  License Class

Street Address

City     State  Zip

Home Phone   Cell Phone

Work Phone     Pager    

Fax   E-Mail Address

Please select your responder preference inside this box First Responder Second Responder Later Responder Will not respond at all Due to age and or health I cannot go into the field  I can help only from home Select a responder option

Please confirm your responder preference by typing your preference in the box below

Whom to notify in case of emergency

Name

Address

City   State Zip

Home Phone   Work Phone

Relationship

Amateur Radio Capabilities

(Check all that apply, a checked box means you have that capability)

HF Mobile and/or Portable Ability

HF Base/Home Operation

HF Phone Patch Ability

VHF HT (2 meters)

VHF Mobile (2 meters)

VHF Base/Home Operation

VHF Mobile APRS Ability

Dual Band HT (2 meters/440)

Dual Band Mobile (2 meters/440)

Dual Band Base/Home Operation (2 meters/440)

In the block below please provide any other amateur radio capabilities you might have that would be beneficial to use in disaster relief (Packet, PSK31, CW, etc)

Georgia Baptist Disaster Relief Training

(Check all that apply, a checked box means you have had that training)

Phase I Communications

Phase II Communications

Unit Director Training

If you have any other information that you would like to provide concerning your ability to serve as a communications volunteer please do so in the space provided below. (Additional training, special skills, etc.)

Date Submitted Month/Day/Year

After you complete filling in your information

please review for accuracy and then click the "SUBMIT" Button