Complete this form to register as an individual or family to participate in the Great California ShakeOut
"drop, cover, and hold on" earthquake drill on October 18, 2012.
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Participation
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I/We will have a Drop, Cover, and Hold On drill at 10:18 am on October 18, 2012.
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Yes
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Number of people in your home that will participate in the ShakeOut, including yourself:
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New! For the 2012 ShakeOut, we are inviting participants to
secure or relocate objects (bookcases, TVs, wall
hangings, etc.) that would cause injury or damage when they fall
during earthquakes. Straps, putty, and other methods for securing
your space are available at all home improvement stores. |
Approximately how many objects in your home, school, or office are
already secured?
(You can update this number later if you need to check) |
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How many objects will you secure before the ShakeOut on October 18,
2012?
(You will be able to report your progress (and have the option to
share photos or videos of your secured objects) and participants who
secure their space will be acknowledged on the lists of
participants for each county.) |
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Is it OK to list your name
as a participant on the ShakeOut.org website or in other materials?
(First and last name, city, year(s) of participation, and if you have pledged to secure your space)
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Yes
No
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Is it OK to share your information with researchers studying the ShakeOut?
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Yes
No
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Contact Information
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Contact Name:
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City:
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State:
ZIP:
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County:
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Country:
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Phone:
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Email:
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(Enter same address twice
to ensure it is correct.)
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One valid email address only per box, please
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From which source(s)
did you learn about the
Great California ShakeOut?
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ShakeOut / Earthquake Country Alliance (email, flyer, etc.)
My employer (email, flyer, etc.)
Another organization (email, flyer, etc.)
My child's school (email, word of mouth, etc.)
Other friends or family (email, word of mouth, etc.)
Facebook, Twitter, or blog
Television, radio, newspaper, or online news
Meeting or preparedness fair
Other:
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| Complete Your Registration: |
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Before submitting your registration, please add info@shakeout.org to your email address list to make sure our confirmation email gets past your spam filter.
Once you click the "Register for the ShakeOut!" button you should see a confirmation page, and receive a confirmation email within a few hours. If the email does not arrive, first look for it in your "spam" folder, then email registration@shakeout.org for assistance.
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