Tama Hills Recreation Center For CFAY/NAF Atsugi Members

Age
M F
RANK
Age
M F
Years of Svc
Child's name
Birthday/
Age
Gender
M F Allergies
Child's name
Birthday/
Age
Gender
M F Allergies
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.
SIGNATURE: DATE:
COMMAND ENDORSEMENT: (Please print legibly.)
I acknowledge that the couple above is planning on attending a Marriage Enrichment Retreat and
I APPROVE / DISAPPROVE their attendance.
Supervisor
SIGNATURE: DATE:
Rank/Position
Permanent Command
Permanent Command/Company
CREDO FAMILY ENRICHMENT RETREAT REGISTRATION
25-27 June 2014
Birth Date Gender
FR
Work Phone Home Phone Cell Phone
Reason for wanting to attend?
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
PRIVACY ACT STATEMENT
Name of Supervisor (E7 & above) Rank
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) ___________________________________
In case of emergency, notify (Name/Phone #):
Branch of Service
E-Mail Address
LAST NAME FIRST NAME MI
SPOUSE'S INFORMATION: (Please print legibly. Fill out only what applies)
Work Phone Home Phone Cell Phone
Supervisor phone Supervisor e-mail
Years of Service
LAST NAME FIRST NAME MI
Birth Date Gender Branch of Service
MILITARY MEMBER INFORMATION: (Please print legibly)
For Meal
Vegetarian only
Any allergic diathesis? ______________________________
For Meal
Command E-mail Distribution Family/Friend
Flyers Facebook CREDO Staff
Other_____________________