Registration Form for Businesses and Organizations

Complete this form to register a business, community group, government agency, medical facility, news media organization, museum, or other organization that will conduct an earthquake drill on September 18, 2009, involving the number of participants entered below. Only a "drop, cover, and hold on" drill is required, though you are encouraged to hold a more extensive test of your emergency plan.

If you give permission below, your organization will be included on the participant list pages for your district.

If you have authority to register your organization, click the check box to begin:

The rest of the form will appear when you check the agreement above.

    Only items marked by " * " are required.

Business/Organization Information
Organization Name:*
(as it should appear on our website
if you give approval below)
Department:
Organization Type:*
Organization Website:
(Include "http://")
District:* Country:
Number of staff or others you represent who will participate:* (digits only -- no text)
Describe your organization's plans
for participating in the ShakeOut
(you can update this later):
Is it OK to list your organization 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

  What has your organization already completed, or what is needed to be done, to be ready for earthquakes? (Optional)

Completed More To Do Not Started

Secure your space (secure furniture and equipment to walls, secure computers from falling, etc.)

Store more water (one gallon per person, per day, for at least 3 days and ideally up to 14 days)

Make sure everyone in your organization knows what to do in a fire (including how to use a fire extinguisher if appropriate)

Create or update disaster plan

Create or update disaster supplies kits

Other:

Contact Person
Contact Name:*    *
Title:
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:

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.

Only items marked by " * " are required.
*Business/Organization Information*
Organization Name:* (as it should appear on our website if you give approval below)
Department:
Organization Type:*
Organization Website: (Include "http://")
District:*	Country:
Number of staff or others you represent who will participate:*	(digits only -- no text)
Describe your organization's plans for participating in the ShakeOut (you can update this later):
Is it OK to list your organization 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 Person*
Contact Name:*	*
Title:
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:


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.