Tama Hills Recreation Center For CFAY/NAF Atsugi Members

Age
M F
RANK/RATE
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 member above is planning on attending a Personal Growth Retreat and
I APPROVE / DISAPPROVE his/her attendance.
Supervisor
SIGNATURE: DATE:
MILITARY MEMBER INFORMATION: (Please print legibly)
For Meal
Vegetarian only
Any allergic diathesis? ______________________________
LAST NAME FIRST NAME MI
Birth Date Gender Branch of Service
E-Mail Address
Supervisor phone Supervisor e-mail
Years of Service
Work Phone
Facebook
Cell Phone
PRI VACY ACT STATEMENT
Name of Supervisor (E7 & above) 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.
(Participant's signature) ___________________________________
In case of emergency, notify (Name/ Phone #):
Command E-mail Distribution Family/Friend
CREDO Staff
How did you find about this retreat?
Have you attended other CREDO programs in the last 3 years?
PGR MER
Other_____________________
CREDO PERSONAL GROWTH RETREAT REGI STRATI ON
14-16 J anuary 2015
FR
Permanent Command
Reason for wanting to attend?
Flyers
Home Phone