CREDO MARRIAGE ENRICHMENT RETREAT REGISTRATION

26-28 March 2014 Izu Imaihama Tokyu Resort For CFAY/NAF Atsugi Members
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 243-8865.

MILITARY MEMBER INFORMATION: (Please print legibly) LAST NAME FIRST NAME MI Age RANK Birth Date M Years of Service Work Phone Home 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 M RANK Years of Service Work Phone Home Phone E-Mail Address For Meal Vegetarian only Any allergic diathesis? ______________________________ Gender F Permanent Command Cell Phone Branch of Service Gender F Permanent Command Cell Phone Branch of Service

Age

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?

Command E-mail Distribution CREDO Staff Family/Friend Other_____________________

How did you find about this retreat? Flyers Facebook

Have you attended other CREDO programs in the last 3 years? PGR Date: Date:
In case of emergency, notify (Name/Phone #):

Y FR

MER Date:

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 or civilian equivalent) Supervisor phone Supervisor e-mail Rank

I acknowledge that the couple above is planning on attending a Marriage Enrichment Retreat and I APPROVE / DISAPPROVE their attendance. Supervisor SIGNATURE: DATE: