CREDO MARRIAGE ENRICHMENT RETREAT REGISTRATION

21-23 January 2015

At a resort in Guam to be announced later. For all service members in Guam

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.

MILITARY MEMBER INFORMATION: (Please print legibly)

LAST NAME
FIRST NAME, MIDDLE INITIAL
PREFERRED NICKNAME
Birth Date

Age

Gender
M

Branch of Service
F

Rank

Years of Service

Permanent Command

Work Phone

Home Phone

Cell 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, MIDDLE INITIAL
PREFERRED NICKNAME
Birth Date

Age

Gender
M

Rank/Job Title

Years of Service

Branch of Service
F
Permanent Command/Workplace

Work Phone

Home Phone

Cell Phone

E-Mail Address
For Meal
Vegetarian only

Any allergic diathesis? ______________________________

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) ___________________________________

How did you find about this retreat?

Flyers

(Spouse 2 signature) ___________________________________

Reason for wanting to attend?

Date of Marriage

Command

Facebook

E-mail Distribution
CREDO Staff

Family/Friend
Other_____________________

Have you attended other CREDO programs in the last 3 years?

PGR
Date:

MER
Date:

Y
FR

Date:

In case of emergency, notify (Name/Phone #):

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

Rank

Supervisor e-mail

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

DATE: