Chaplain Corps Activities Registration

Register for Annual Religious Education Programs and Groups

Religious Interest
-- Choose support type --CatholicJewishProtestant

Your Name (required)

Your Email (personal preferred) (required)

Name of Registrant (required)

Note: Please submit one form per person being registered.

Age of Registrant (required)
0123456789101112131415161718Adult

Please read through these sentences, and check the box to the right of each option to respond "yes", or "no."

I grant approval for my child (or agree as an adult) to participate in this chapel program and hereby release
the Garrison Chaplain’s office from any liability arising from participation.YesNo

I give consent for the chapel team to give or seek medical aid required in the case of an emergency. YesNo
※ If you answer no, then the Garrison Chaplain’s Office will contact you for a confidential conversation so that we can partner with you for your best care and participation.

I give permission to the Garrison Chaplain’s office to use photographs or videos that are taken of me / my
child while participating in this program for use in chapel publicity material. YesNo

I give permission for my contact information to be used by the selected program in a congregational
directory and for congregational emails.YesNo

Do you / your child have any allergies or Special Needs that the chapel leaders should be aware of? YesNo
※ If you answer yes, then the Garrison Chaplain’s Office will contact you for a confidential conversation so
that we can partner with you for your best care and participation.

Would you be interested in volunteering for chapel events? YesNo

Additional authorizations may be required based on activity or program.(Examples include overnight events, chapel childcare, and the AMS Assessment Process.)

Message to RSO (optional)

Privacy Statement

To register for an activity, you must accept the terms of the Privacy Statement: Privacy Act Statement 1. AUTHORITY: The information is being collected IAW the provisions of 5 USC 301. 2. PURPOSE: To provide data on religious education needs to determine and administer educational training to the military community served. To record attendance and participation in chapel programs. 3. ROUTINE USES: Any information you provide is disclosed to members of the Dept. of Defense who have a need for the information in the performance of their duties. In addition, the information may be disclosed to federal, state, and local government agencies outside of the Dept. of Defense specified in “Blanket Routine Use”, 48 Federal Register 25502. 4. VOLUNTARY DISCLOSURE: Providing the information is voluntary. There will be no adverse effect on you for not furnishing the information other than that certain information may not otherwise be available. FOR OFFICIAL USE ONLY: This information may be disseminated within the DoD components and between officials of the DoD components and DoD contractors, consultants, and grantees as necessary in the conduct of official business. FOUO information may also be released to officials in other departments and agencies of the executive and judicial branches in performance of a valid government function. (DoD Directive 5400.11, "Department of Defense Privacy Program," May 8, 2007.) This is to provide tracking of chaplains' compliance to the regulations on child protection (Public Law 101-647, DoDI 1402.5, Army Directive 2014-23, "Chief of Chaplains Child Protection Guidance at Chaplain Sponsored Events" 10 March 2016). I accept the terms in the Privacy Statement. (required)