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Associate Application
Preparedness Agreement
Research shows that people are most likely to improve their preparedness when they see people they know get prepared. With this in mind, please begin your registration by confirming that you agree to the following
*
:
Yes! As an ECA Associate, I will take actions in my home and workplace to improve my preparedness for earthquakes, and encourage others to do the same.
Tell Us About Yourself
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Password (min length: 8 characters)
Confirm Password (min length: 8 characters)
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Congo, the Democratic Republic of the
Cook Islands
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India
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Iraq
Ireland
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Israel
Italy
Jamaica
Japan
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Korea, Republic of
Kuwait
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Portugal
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Romania
Russian Federation
Rwanda
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
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Samoa
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Saudi Arabia
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Serbia
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Slovenia
Solomon Islands
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Sudan
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Tajikistan
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Thailand
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Virgin Islands, U.S.
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What languages do you speak? (select all that apply)
English
Spanish
Afar
Abkhazian
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French
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Galician
Guarani
Gujarati
Manx
Hausa
Hebrew
Hindi
Hiri Motu
Croatian
Haitian
Hungarian
Armenian
Herero
Interlingua (International Auxiliary Language Association)
Indonesian
Interlingue
Igbo
Sichuan Yi
Inupiaq
Ido
Icelandic
Italian
Inuktitut
Japanese
Javanese
Georgian
Kongo
Kikuyu
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Khmer
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Latin
Luxembourgish
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Malay
Maltese
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Nepali
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Dutch
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Norwegian
South Ndebele
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Polish
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Portuguese
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Raeto-Romance
Kirundi
Romanian
Russian
Kinyarwanda
Sanskrit
Sardinian
Sindhi
Northern Sami
Sango
Sinhala
Slovak
Slovenian
Samoan
Shona
Somali
Albanian
Serbian
Swati
Southern Sotho
Sundanese
Swedish
Swahili
Tamil
Telugu
Tajik
Thai
Tigrinya
Turkmen
Tagalog
Tswana
Tonga
Turkish
Tsonga
Tatar
Twi
Tahitian
Uighur
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Urdu
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Venda
Vietnamese
Volapuk
Walloon
Wolof
Xhosa
Yiddish
Yoruba
Zhuang
Chinese
Zulu
Work Phone
Mobile Number
Twitter (Enter as twitter.com/username)
Facebook (Enter as facebook.com/username)
Tell Us About Who You Are Representing
Which organization should be listed for your affiliation?
Organization listed above
None (I am not representing my organization)
Another organization (specify below)
Affiliated organization name
Please provide the website of the organization you specified here. It will be linked on websites where you are listed (with your permission) as an ECA Associate (Please include "http://" at the beginning of the URL)
Please choose the category below that best describes you and/or your affiliated organization:
Individuals/Families
Childcare and Pre-Schools
K-12 Schools and Districts
Colleges and Universities
Local Government
State Government
Federal Government
Tribes/Rancherias
Businesses
Healthcare
Senior Facilities/Communities
Disability/AFN Organizations
Non-Profit Organizations
Neighborhood Groups
Preparedness Organizations
Faith-based Organizations
Museums, Libraries, Parks, etc.
Volunteer/Service Clubs
Youth Organizations
Animal Shelter/Service Provider
Agriculture/Livestock
Volunteer Radio Groups
Science/Engineering Organizations
Media Organizations
What communities or organizations do you serve, or have an expertise in? (select all that apply)
Individuals/Families
Childcare and Pre-Schools
K-12 Schools and Districts
Colleges and Universities
Local Government
State Government
Federal Government
Tribes/Rancherias
Businesses
Healthcare
Senior Facilities/Communities
Disability/AFN Organizations
Non-Profit Organizations
Neighborhood Groups
Preparedness Organizations
Faith-based Organizations
Museums, Libraries, Parks, etc.
Volunteer/Service Clubs
Youth Organizations
Animal Shelter/Service Provider
Agriculture/Livestock
Volunteer Radio Groups
Science/Engineering Organizations
Media Organizations
What earthquake awareness or preparedness activities do you or your company organize, if any? (Include any print materials you may distribute or web pages you manage.)
Tell Us How You'll Participate
With which regional alliances do you wish to participate? (choose one or more)
Earthquake Country Alliance Southern California
Earthquake Country Alliance Bay Area
Redwood Coast Tsunami Work Group
None
Which sector based committees are you interested in? (select all that apply)
Business Committee
EPIcenter Network Committee
Evaluation Committee
Fire Advisory Committee
Healthcare Committee
Higher Education Committee
K-12 Schools Committee
Multi-Cultural Committee
Non-Profit & Faith-Based Committee
Public Sector Committee
Seniors and People with Disabilities Committee
Which outreach bureaus are you interested in? (select all that apply)
Participation Bureau (Shakeout and Tsunami Week Recruitment)
Media Bureau (TV, radio, print, and social media engagement)
Speakers Bureau (Presentations about earthquake topics)
Events Bureau (Representation of ECA/Shakeout at preparedness fairs and other events)
How else can you contribute as an ECA Associate?
Do you agree to request approval if you want to use any ECA/ShakeOut branding (name, logo, graphics, etc.) on print or web materials that you might develop?
Yes
No
Is it OK to list you as an ECA Associate on our public websites? Only your name, affiliation (if provided), website, and location will be listed publicly.
Yes
No
Do you give approval for your contact information to be listed on the password-protected ECA Associates webpage, to facilitate collaboration?
Yes
No
Only fill in if you are not human