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