1
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. 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: For all the Sailors in Singapore. Cell Phone Permanent Command/Workplace Work Phone 30 May-01 June 2015 Home Phone Rank Work Phone Home Phone Cell Phone For Meal Vegetarian only Any allergic diathesis? ______________________________ SPOUSE'S INFORMATION: (Please print legibly. Fill out only what applies) Supervisor phone Supervisor e-mail 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. (Spouse 1 signature) ___________________________________ (Spouse 2 signature) ___________________________________ Date of Marriage Reason for wanting to attend? In case of emergency, notify (Name/Phone #): Flyers Facebook CREDO Staff Other_____________________ 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 Family/Friend Command E-mail Distribution CREDO MARRIAGE ENRICHMENT 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 Defense’s 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. Permanent Command MILITARY MEMBER INFORMATION: (Please print legibly) LAST NAME FIRST NAME, MIDDLE INITIAL PREFERRED NICKNAME Birth Date Gender Branch of Service
