Registration Form for Schools

Complete this form to register a school that will conduct an earthquake drill on 18 September 2009, involving the number of staff and students entered below.

Only a simple "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 listed with others on the school participant list page for your district.

ATTENTION

Resources for planning your drill, getting prepared, and encouraging others to participate are available at www.shakeout.org/nzwestcoast/schools.

REGISTRATION FORM
Only items marked by " * " are required.
If you have authority to register your organization, click the check box to begin:

  Yes!*
We will participate in the ShakeOut drill on 18 September 2009,
and I have authority to register the school or educational institution listed below.
Organization Information
Name of School or Educational Institution:*
Please select:*
What type?:
Website:
(Include "http://")
District:*
Which years does your school include?: Preschool   1   2   3   4   5   6   7   8   9   10   11   12   13   Adult   Undergraduate   Graduate
Country:
Total number of staff who will participate:*  (digits only -- no text, no ranges)
Total number of students who will participate:  (digits only -- no text, no ranges)
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)

CompletedMore To DoNot 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 all staff 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
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 "Regiser 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.

Designed by Weston/Mason©2012 SCEC Southern California Earthquake Center USC
West Coast ShakeOut