Secure NOKR Registration Form

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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:

MI:

*Last Name:

*Birthday: (mm/yr, ex:05/65) For security reasons

*Address:

*City:

*Zip/Postal Code:

*State /Province:

*Country:

*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)

If you have any additional questions or comments Please contact us at volunteer@pleasenotifyme.org