CREDO FAMILY ENRICHMENT RETREAT REGISTRATION

16-18 June 2015

Luigan's Spa & Resort, Fukuoka For CFAS commands
MILITARY MEMBER INFORMATION: (Please print legibly)
LAST NAME
FIRST NAME
MI
Age

Birth Date

Gender

Rank

Years of Service

Branch of Service
F
Permanent Command

Work Phone

Home Phone

Cell Phone

E-Mail Address
For Meal
Vegetarian only

Any allergic diathesis? ______________________________

SPOUSE'S INFORMATION: (Please print legibly. Fill out only what applies)
LAST NAME
FIRST NAME
MI
Birth Date

Age

Gender
M

Rank/Position

Branch of Service
F
Permanent Command/Company

Years of Svc

Work Phone

Home Phone

Cell Phone

E-Mail Address
For Meal
Vegetarian only

Any allergic diathesis? ______________________________

Birthday/
Gender
Age
M
F
Allergies
Birthday/
Gender
Age
M
F
Allergies

Child's name
Child's name

I hereby grant permission to the rights of my and my children's image, likeness, and sound of our 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 our 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) ___________________________________

Reason for wanting to attend?

Command

How did you find about this retreat?

Flyers

Facebook

E-mail Distribution

Family/Friend

CREDO Staff

Other_____________________

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

Personal Growth/Resiliency
Date:

Marriage Enrichment
Date:

Family Enrichment
Date:

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

PR I VACY ACT STATEM EN T

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 family above is planning on attending a Family Enrichment Retreat and
I
APPROVE /
DISAPPROVE their attendance.
Supervisor
SIGNATURE:

DATE: