As a licensed Amateur Radio Operator, I request that I be included as a 
Member of the Amateur Radio Support Group ("ARSG") which has been formed to 
assist the City of Watertown and Town of Ixonia Divisions of Emergency 
Government in the event an emergency occurs in the greater Watertown/Ixonia 
area.  The ARSG also may be activated as part of the Amateur Radio Emergency 
Service ("ARES") or Radio Amateur Civil Emergency Service ("RACES") at times 
when it may be advantageous to operate under such authority.

     I agree to take part in training programs offered to ARSG Members from 
time to time, and will comply with all of the rules and procedures established 
by the Divisions of Emergency Government and the ARSG.  I also consent to have 
my name, callsign, home address and telephone number (and business address and 
telephone number if shown below) placed on the List of ARSG Members that will 
be furnished to City of Watertown and Town of Ixonia Emergency Government 
officials and their respective law enforcement personnel.

     I further release the Watertown Amateur Radio Club, UA and the ARSG 
Coordinators from any and all liability for injury to me or my property which 
may result from my participation as an ARSG Member.  I acknowledge that I am 
volunteering to participate because I am a concerned citizen and a licensed 
radio amateur interested in providing emergency communications as a public 

Date _________________________       Signature ________________________________                            

                                  PLEASE PRINT

Full Name _____________________________________ Callsign ______________________  

Home Address __________________________________ License Class _________________

City, State, Zip ______________________________ Telephone # ___________________


E-mail Address ________________________________

Business Address ______________________________ Bus. Tel. # ___________________

City, State, Zip ______________________________

Rev: September 22, 2003


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