CREDO MARRIAGE ENRICHMENT RETREAT REGISTRATION

22-24 January 2014 Izu Imaihama Tokyu Resort MILITARY MEMBER INFORMATION: (Please print legibly) LAST NAME FIRST NAME MI Age RANK Birth Date F
PAYGRADE (E1-O10)

Sex M RTD PRD

Branch of Service DEROS

Years of Service

Permanent Command Home Phone E-Mail Address For Meal Cell Phone

Work Phone

Vegetarian only

Any allergic diathesis? ______________________________

SPOUSE'S INFORMATION: (Please print legibly. Fill out only what applies) LAST NAME FIRST NAME MI Age RANK Birth Date F
PAYGRADE (E1-O10)

Sex M RTD PRD

Branch of Service DEROS

Years of Service

Permanent Command Home Phone E-Mail Address For Meal Cell Phone

Work Phone

Vegetarian only

Any allergic diathesis? ______________________________

I hereby grant permission to the rights of my image, likeness, and sound of my voice as recorded on audio or video tape without payment or any other consideration. I hereby waive the right to inspect or approve the finished product wherein my likeness appears. I also understand that this material may be used in diverse noncommercial, nonprofit settings within an unrestricted geographic area. (Spouse 1 signature) ______________________________ (Spouse 2 signature) ______________________________

Date of Marriage

Reason for wanting to attend? Y FR Date: N

Have you attended other CREDO programs last 3 years? PGR Date: Date:
In case of emergency, notify (Name/Phone #):

MER

PRIVACY ACT STATEMENT

UNDER THE AUTHORITY OF 5 U.S.C. 301 (DEPARTMENT REGULATIONS), THE ABOVE INFORMATION IS REQUESTED FOR THE PURPOSE OF KEEPING RECORD OF ALL PERSONNEL WHO HAVE PARTICIPATED IN THE CREDO PROGRAM. THE RANK/RATE, NAME, ADDRESS, AND PHONE NUMBERS WILL BE USED IN THE FORM OF A ROSTER AT THE END OF YOUR RETREAT. FURNISHING THIS INFORMATIONS IS ENCOURAGED, BUT NOT MANDATORY. ANY INDIVIDUAL WHO DOES NOT SIGN AND DATE THIS PRIVACY ACT STATEMENT WILL BE EXCLUDED FROM THE FOREMENTIONED ROSTER.

SIGNATURE:

DATE:

COMMAND ENDORSEMENT: (Please print legibly.)

Name of Supervisor (E7 & above or civilian equivalent) Supervisor phone Supervisor e-mail Rank

I acknowledge that the couple above is planning on attending a Marriage Enrichment Retreat and I APPROVE / DISAPPROVE their attendance. Supervisor SIGNATURE:

DATE: