Registration Form for Schools/Colleges

Complete this form to register a K-12 public and private school, school district, pre-school, college, or university that will conduct an earthquake drill on October 21, 2010, involving the number of staff and students entered below. (Resources for planning your drill are available.)

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 or college participant list page for your county.

ATTENTION

Past participants: If you registered your school or organization in 2008 or 2009, please login to register for 2010. (You will not need to enter everything again.)

You can request your access code for the login if you have forgotten it.

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 October 21, 2010, and
I have authority to register the school, district, or organization listed below.
Organization Information
Name of School, District or Organization:*
Please select:*
What type?:
Website:
(Include "http://")
County:*
If your district or organization spans multiple counties, please complete separate registration forms for your participants in each county
District (if applicable):
Please include full name, such as "Johnson Valley Unified School District"
Which grade levels does your school or district include?: Preschool   K   1   2   3   4   5   6   7   8   9   10   11   12   Adult   Undergraduate   Graduate
Address:
City:*
State:
Zip Code:*
Country:
Total number of schools or sites participating:  (digits only -- no text, no ranges)
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):
New! For the 2010 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)
How many objects will you secure before the ShakeOut on October 21, 2010?                      
(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.)
Is it OK to list your organization as a participant on the ShakeOut.org website or in other materials?
(Name, department, district (if applicable), city, year(s) of participation, and if you have pledged to secure your space) *		  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 California ShakeOut?: ShakeOut / Earthquake Country Alliance (email, flyer, etc.)
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.)
Facebook, Twitter, or blog
Television, radio, newspaper, or online news
Meeting or preparedness fair
Other:

Complete Your Registration:

Before submitting your registration, please add info@shakeout.org to your email address list to allow our confirmation email to get 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 info@shakeout.org for assistance.

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