CREDO CARE FOR CAREGIVERS RETREAT REGISTRATION

09-11 July 2014 Tama Hills Lodge For Religious Ministries Teams under CNRJ Chaplain's AOR PARTICIPANT INFORMATION: (Please print legibly) LAST NAME FIRST NAME Birth Date F
RANK/RATE

MI

Age

Sex M PRD

Branch of Service
Command/Employment

Occupation

Years of Service

Mailing Address Work Phone Home Phone E-Mail Address For Meal Vegetarian only
How did you hear about this retreat? E-mail Distribution Flyer

Cell Phone

Any allergic diathesis? ______________________________

Command Facebook Family/Friend Ombudsman/FRG Other _______________________

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. (Participant's signature) ______________________________ Reason for wanting to attend?

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:

PRIVACY ACT STATEMENT

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 person above is planning on attending a Personal Growth Retreat and I APPROVE / DISAPPROVE his/her attendance. Supervisor SIGNATURE: DATE: