Fillable MFP CREDO MCIWEST Program Event Application

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MFP CREDO MCIWEST Program Event Application

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  • 16 check-boxes
  • 62 other fields

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IF APPLICABLE TO THE SELECTED PROGRAM
MARINE CORPS INSTALLATIONS WEST
MARINE CORPS BASE, CAMP PENDLETON
CHAPLAIN ENRICHMENT RELIGIOUS DEVELOPMENT OPERATION (CREDO)
PROGRAM/EVENT APPLICATION FORM
OFFICE NUMBER: (760)-725-4954
LOCATION: Marine Corps Base,
Camp Pendleton, BLDG 1344
WEBSITE: www.mccscp.com/credomciwest
Facebook Page: CREDO MCIWEST
Instagram Page: CREDO MCIWEST
Rank:
Gender:
Name (Last, First, MI):
Branch:
Gender:
Branch:
DoD ID:
Work Phone Number:
Cell Phone Number:
Spouse/Fiance First Name:
Work Phone Number:
Work E-mail Address:
Work E-mail Address:
Personal E-mail Address:
Cell Phone Number:
List any special needs, dietary restrictions, or food allergies below:
List all children attending the program by name, age, gender, relationship, as well as any dietary restrictions and allergies (food, drugs, pollen, etc.).
Name (Last, First, MI)
Age/Gender(M/F)
Relationship
Diet Restriction
Allergies
Choose which program:
To:
From:
Today's Date:
PRIVACY ACT STATEMENT
SORN NM01730-1
AUTHORITY: 10 U.S.C. 5013, Secretary of the Navy; 10 U.S.C. 5041, Headquarters, Marine Corps; and SECNAVINST 1730.9, Confidential Communications to
Chaplains.
PRINCIPLE PURPOSE: To provide and document confidential pastoral care given to counselees who have participated in the CREDO MCIWEST
Program.
ROUTINE USES: In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act, these records or information contained therein may
specifically be disclosed outside the DoD as routine use pursuant to 5 U.S.C. 552a(b)(3).
DISCLOSURE: The rank/rate, name, address, e-mail, and phone numbers will be used to create a roster at the end of your event. Furnishing this information is
highly encouraged. Any individual who does not sign and date this form will be excluded from the aforementioned roster.
It is the Department of Defense's policy to treat all service members equally. CREDO MCIWEST programs are open to all Active Duty service members
and dependents. The goals of these programs are to strengthen relationship and personal development skills in an environment that is free from the every-day
distractions of life. Participants, chaplains, and support personnel in these programs may have religious views that differ from your own. These programs
will be conducted in a manner that is sensitive to the diverse religious, spiritual, moral, cultural, and personal beliefs of the participants.
*Some of these may not apply to all programs.*
GENERAL INFORMATION
Personal E-mail Address:
Rank:
Unit:
Date of Marriage:
Name (Last, First, MI):
Work Phone Number:
Address:
MARINE CORPS INSTALLATIONS WEST
MARINE CORPS BASE, CAMP PENDLETON
CHAPLAIN ENRICHMENT RELIGIOUS DEVELOPMENT OPERATION (CREDO)
OFFICE NUMBER: (760)-725-4954
LOCATION: Marine Corps Base,
Camp Pendleton, BLDG 1344
WEBSITE: www.mccscp.com/credomciwest
Facebook Page: CREDO MCIWEST
Instagram Page: CREDO MCIWEST
Relationship:
Cell Phone Number:
State:
YES
NO
YES
NO
COMMAND INFORMATION AND SUPERVISOR RECOMMENDATION
I acknowledge that the CREDO MCIWEST program/event for which the service member is registering, is his or her appointed
place of duty for the duration of the program/event. The member is allowed to take time-off for travel to the event site stated in the
confirmation e-mail sent from the CREDO MCIWEST office. If required by this command, Permissive Temporary Additional
Duty (TAD)/No-Cost TAD orders will be issued. The member's supervisor/Officer-In-Charge (OIC) will ensure that the member
fulfills their obligation to the CREDO MCIWEST office. In the event of a cancellation or an emergency, the member will contact
CREDO MCIWEST. Failure to show will result in the misuse of Marine Corps funds.
SNCOIC/OIC/SUPERVISOR SIGNATURE:
E-
mail:
Work Phone Number:
Cell Phone Number:
YES
YES
YES
YES
NO
NO
NO
NO
APPROVED
DISAPPROVED
Today's Date:
Service Member Signature:
Today's Date:
From:Location:
To:
Retreat Name:
EMERGENCY CONTACT INFORMATION
SNCOIC/OIC/SUPERVISOR (Last, First, MI): Rank:
City:
STATEMENT OF UNDERSTANDING AND AUTHORIZATION
Please read and check Yes or No:
I understand that I forfeit my slot for the event, if I fail to submit this form before the deadline.
I understand that, if I am selected, but consequently unable to attend this event, I must cancel with the CREDO MCIWEST
staff immediately to ensure my spot is filled by another applicant.
I understand that my appointed place of duty is the event site. If I fail to show without a confirmed cancellation acknowledged
by the CREDO MCIWEST office, my command will be notified.
I understand that CREDO MCIWEST is a voluntary program. Alcohol WILL NOT be consumed at the event. Any last
minute cancellations, "no shows", will result in my command being notified immediately.
I understand that I must inform CREDO MCIWEST, upon confirmation of attendance, should I need to bring a service
animal, as defined by the ADA, to the retreat. I understand that I must also notify the hotel in advance and that additional
charges will not be covered by CREDO MCIWEST.
I understand that pictures may be taken throughout the event, and if I do not wish to participate, I may politely decline.
Have you attended any CREDO MCIWEST retreats in the last 12 months? If you have, please specify the dates you have
attended below. You will be placed on the wait list to allow others the opportunity to attend.
Zip Code:
YES
YES
NO
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MFP CREDO MCIWEST Program Event Application

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Completed 20 May 2022

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