CREDO PERSONAL RESILIENCY RETREAT REGISTRATION

For NAVBASE Guam and Andersen AFB

10-12 March 2015
Pacific Star Resort & Spa
MILITARY MEMBER INFORMATION: (Please print legibly)
LAST NAME
FIRST NAME, M.I.
PREFERRED NICKNAME

Age

Birth Date

Gender
M

Rank/Rate

Branch of Service
F

Years of Service

Permanent Command

Work Phone

Home Phone

Cell Phone

Work E-Mail Address

Personal E-mail Address

For Meal

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.
(Participant's signature) ___________________________________

Reason for wanting to attend?

How did you find about this retreat?

Flyers

Command

Facebook

E-mail Distribution
CREDO Staf

Family/Friend
Other_____________________

Have you attended other CREDO programs in the last 3 years?

Personal Growth/Resiliency
Date:

Marriage Enrichment
Date:

Family Retreat
Date:

In case of emergency, notify (Name/Phone #):

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)
Supervisor phone

Rank

Supervisor e-mail

I acknowledge that the member above is planning on attending a Personal Resiliency Retreat and
I
APPROVE /
DISAPPROVE his/her attendance.
Supervisor
SIGNATURE:

DATE: