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.

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 service members in Yokosuka/Atsugi

Cell Phone

Permanent Command/Workplace

Work Phone

23-25 July 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 StaffOther_____________________

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?

Personal Growth/Resiliency Marriage Retreat

For Meal

Family Retreat

Family/FriendCommand 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 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.

Permanent Command

MILITARY MEMBER INFORMATION: (Please print legibly)

LAST NAME FIRST NAME, MIDDLE INITIAL PREFERRED NICKNAME

Birth Date Gender Branch of Service

James.Nilo.CTRTypewritten Text

James.Nilo.CTRTypewritten TextReturn to CNRJ.CREDO.Japan@fe.navy.mil or FAX DSN 243-8874

LAST NAMERow1: FIRST NAME MIDDLE INITIALRow1: PREFERRED NICKNAMERow1: AgeRow1: Birth DateRow1: Branch of ServiceF: Years of ServiceRow1: RankRow1: Permanent CommandRow1: Work PhoneRow1: Home PhoneRow1: Cell PhoneRow1: EMail AddressRow1: Any allergic diathesis: LAST NAMERow1_2: FIRST NAME MIDDLE INITIALRow1_2: PREFERRED NICKNAMERow1_2: AgeRow1_2: Birth DateRow1_2: Branch of ServiceF_2: Years of ServiceRow1_2: RankJob TitleRow1: Permanent CommandWorkplaceRow1: Work PhoneRow1_2: Home PhoneRow1_2: Cell PhoneRow1_2: EMail AddressRow1_2: Any allergic diathesis_2: Date of MarriageRow1: Reason for wanting to attendRow1: Date: Date_2: Date_3: In case of emergency notify NamePhone: Name of Supervisor E7 above or civilian equivalentRow1: RankRow1_2: Supervisor phoneRow1: Supervisor emailRow1: Check Box1: Check Box2: Check Box3: Check Box4: Check Box5: Check Box6: Check Box7: Check Box8: Check Box9: Check Box10: Check Box11: Check Box12: Check Box13: Check Box14: Check Box15: Text16: Check Box17: Check Box18: Text20: Check Box21: Check Box22: Text24: