Izu Imaihama Tokyu Resort

Age
M F
Years of Service
Age
M F
Years of Service
Y N
Date: Date: Date:
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.
MEMBER'S SIGNATURE: DATE:
COMMAND ENDORSEMENT: (Please print legibly.)
I acknowledge that the couple/member above is planning on attending a Care for Caregroup Retreat
and I APPROVE / DISAPPROVE their attendance.
Supervisor
SIGNATURE: DATE:
MILITARY MEMBER INFORMATION: (Please print legibly)
LAST NAME FIRST NAME, MIDDLE INITIAL PREFERRED NICKNAME
Birth Date Gender Branch of Service
Permanent Command Rank
Permanent Command/Workplace
CREDO CARE FOR CAREGROUP RETREAT REGISTRATION
Birth Date Gender Branch of Service
Rank/Job Title
E-Mail Address
LAST NAME FIRST NAME, MIDDLE INITIAL PREFERRED NICKNAME
It is the Department of Defenses policy to treat all married military couples equally. Marriage Enrichment Retreats and Family
Enrichment Retreats are open to all married military couples. The goal of the retreat is to strengthen relationship skills in an
environment that is free from the every-day distractions of life. Participants, chaplains, and support personnel in these retreats
may have religious views that differ from your own religious views. This retreat will be conducted in a manner that is sensitive
to the diverse religious, spiritual, moral, cultural, and personal beliefs of the participants. The chaplain leading this retreat
views marriage as being between a man and a woman. If you have any questions regarding the retreat please call our CREDO
office at DSN (315) 243-8865.
Work Phone Home Phone Cell Phone
E-Mail Address
Vegetarian only Any allergic diathesis? ______________________________
How did you find about this retreat?
Have you attended other CREDO programs in the last 3 years?
PGR MER
For Meal
FR
PRIVACY ACT STATEMENT
Name of Supervisor (E7 & above or civilian equivalent) Rank
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.
(Member's signature) ___________________________________ (Spouse's signature) ___________________________________
Date of Marriage Reason for wanting to attend?
In case of emergency, notify (Name/Phone #):
Flyers Facebook CREDO Staff
Other_____________________
Cell Phone
Supervisor phone Supervisor e-mail
16-18 July 2014 For CNRJ RMT Members
Command E-mail Distribution Family/Friend
For Meal
Vegetarian only
Any allergic diathesis? ______________________________
SPOUSE'S INFORMATION: (Please print legibly. Fill out only what applies)
Work Phone Home Phone