CREDO PERSONAL 5(6,/,(1&< RETREAT REGISTRATION

20-22 January 2016

Tama Hills Recreation Center
MILITARY MEMBER INFORMATION: (Please print legibly)
LAST NAME
FIRST NAME
MI
Birth Date

Age

Gender
M

Branch of Service
F

Years of Service

RANK/RATE

Permanent Command

Work Phone

Home Phone

Cell Phone

E-Mail Address (Required)

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 Staff

Family/Friend
Other_____________________

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

Personal Growth/Resiliency
Date:

Family Retreat

Marriage Enrichment
Date:

Date:

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

P RI VACY ACT STATEM ENT

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:

Send to FAX 243-8874 or e-mail to CNRJ.CREDO.Japan@fe.navy.mil