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
service.
Date _________________________ Signature ________________________________
PLEASE PRINT
Full Name _____________________________________ Callsign ______________________
Home Address __________________________________ License Class _________________
City, State, Zip ______________________________ Telephone # ___________________
OPTIONAL
E-mail Address ________________________________
Business Address ______________________________ Bus. Tel. # ___________________
City, State, Zip ______________________________
Rev: September 22, 2003
