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NOKR (Emergency Contact Registry  Volunteer) REGISTRATION FORM
We will never sell or disseminate your information.
Please complete the following information to register. You only need to register once.
*) denotes a required field.

Demographic Info

*First Name:

*Last Name:
*Birthday: (mm/yr, ex:05/65) For security reasons
*Zip/Postal Code:
*State /Province:
*Daytime Phone:
Evening Phone:
Other Number:
*Email Address:
Additional Email:

*Have you ever been arrested, charged, "questioned as an accused party", or convicted of a felony or misdemeanor, including court martial and military charges? (Omit traffic violations).

*Yes No If yes, please provide more information below.


Do you own a wireless device Yes No (Palm, Black Berry etc.)
Do You have internet access Yes No

*Are you under 18 years of age?     Yes   No

*Briefly please tell us who you are and how you will help your community as a NOKR volunteer

 (Maximum 500 characters)


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