DID YOU KNOW?

If you give permission to be listed as a participant, you will be included on the participant list page for your district.


Individual and Family Registration Form

Due to planned power outages for electrical work, our servers are currently unable to accept registrations. If you attempt to register now, your registration will NOT be processed. This message will be removed as soon as power is restored.

Complete this form to register as an individual or family to participate in New Zealand's Great West Coast ShakeOut "drop, cover, and hold on" earthquake drill on 18 September, 2009.

Only items marked by " * " are required.

Participation

I/We will have a Drop, Cover, and Hold On drill at 10:10 am on 18 September 2009.*		 Yes
Number of people in your home that will participate in the ShakeOut, including yourself: *

I agree to receive emails about the ShakeOut and other earthquake information:*
Yes
No

Is it OK to list your name (first and last names only, no other info) as a participant on the ShakeOut.org.nz website or in other materials?*  Yes
 No
Is it OK to share your information with researchers studying the ShakeOut?*       Yes
 No
Contact Information
Contact Name: *    *
District:    Country:  
Phone:
Email: *
(Enter same address twice
to ensure it is correct.)
One valid email address only, please

From which source(s)
did you learn about the
Great West Coast ShakeOut?		 ShakeOut brochure
My employer (email, flyer, etc.)
Another organization (email, flyer, etc.)
My child or my child's school (email, word of mouth, etc.)
Other friends or family (email, word of mouth, etc.)
Newsletter, blog, or social website
Television, radio, newspaper, or online news
Other:
What have you already completed, or what is needed to be done, to be ready for earthquakes? (Optional):
CompletedMore To DoNot Started
Secure your space (secure furniture to walls, secure electronics, etc.)
Store more water (one gallon per person, per day, for at least 3 days and ideally up to 14 days)
Get a fire extinguisher and make sure everyone in my household knows how to use it
Create or update disaster plan
Create or update disaster supplies kits
Other:
Complete Your Registration:

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 info@shakeout.org.nz for assistance.

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West Coast ShakeOut