( insert unit name ) Family Readiness Information (Please fill in all applicable areas) PRIVACY ACT STATEMENT AUTHORITY: Title 10, USC, Section 3012. PRINCIPLE PURPOSES): To assist Army Agencies and Commands in their mission of providing care and assistance to families of Service members who are required to be away from their home station. ROUTINE USES: (1) To identify specific problems and service needs of Soldiers and their families. (2) To gather data that will assist in the development of appropriate programs and services. (3) To serve as a record of services provided. MANDATORY OR VOLUNTARY DISCLOSURE AND EFFECT ON INDIVIDUAL NOT PROVIDING INFORMATION: Voluntary information is required to assist the individual and his/her family members. Failure to provide the required information could result in a delay in providing assistance to the individual and/or family members.
Military member’s name: ______
Spouse/next of kin’s name: ______
Home address:______
Home phone ______
E-Mail address: ______
Place of employment: ______Work phone:______
Please list all children: Name ______Age______School______
Name ______Age______School______
Name ______Age______School______
Name ______Age______School______
Do you have any special needs or circumstances you would like the FRG to be aware of during a deployment? Yes _____ No _____
Explanation: ______
Do you have a reliable vehicle? ______
Do you have a drivers’ license? ______
Are you expecting a child? If so, when is the baby due? ______
What is your native language? ______
EMERGENCY CONTACT:
Other than your service member, who should be notified in an emergency (friend/neighbor, family member)?
Name: ______Relationship:______
Phone: ______Address: ______
Source: Texas A&M University CASUALTY NOTIFICATION
In the event of casualty notification, who LOCALLY would you want to have with you for support?
Name______Relationship ______
Phone number ______
Name ______Relationship ______
Phone number: ______
Name ______Relationship ______
Phone number ______
FRG INFORMATION
Could you help with any of the following? (Check any that apply.)
FRG Activities ___; Telephoning ___; Fundraising ___; Newsletter ___; Baking/Cooking ___;
Planning: ___; Emergency meals ___; Welcoming new families: ___; Virtual FRG ___;
Other (Specify)
What topics would you like to discuss or hear about at a Family Readiness Group meeting? ______
Do you wish to be contacted by the FRG key caller? ______
In order to receive information from the Family Readiness Group, family members must sign the privacy act statement, agreeing to have their name and phone number printed on the phone tree list, which is distributed to the appropriate volunteer.
YES, I will allow my name and phone number to be printed on the phone tree roster to be called for unit informational purposes and social functions.
Signature: ______Date: ______
NO, do not release my name and number to the phone tree call roster. I understand that I may not receive information about the unit, the FRG, or its activities.
Signature: ______Date: ______Family Assistance Information Sheet
PRIVACY ACT STATEMENT AUTHORITY: Title 10, USC, Section 3012. PRINCIPLE PURPOSES): To assist Army Agencies and Commands in their mission of providing care and assistance to families of Service members who are required to be away from their home station. ROUTINE USES: (1) To identify specific problems and service needs of Soldiers and their families. (2) To gather data that will assist in the development of appropriate programs and services. (3) To serve as a record of services provided. MANDATORY OR VOLUNTARY DISCLOSURE AND EFFECT ON INDIVIDUAL NOT PROVIDING INFORMATION: Voluntary information is required to assist the individual and his/her family members. Failure to provide the required information could result in a delay in providing assistance to the individual and/or family members.
1. Sponsor Information:
Name: ______
Rank/Grade: ______SSN:______
Address:______Street City State Country Zip
Home Phone Number w/ Area Code:______
2. Military Status: Active_____ National Guard_____ USAR (TPU)____ USAR(IMA)_____ USAR (IRR)_____ CIV_____
Unit:______
Unit Address:______
3. Marital Status: Single ______Married ______Divorced ______
4. Spouse’s Name: ______
5. Children: Yes_____ No_____
Name(s) Age School/Childcare Provider ______
______
______
6. Primary Next Of Kin (PNOK)
Name:______Relationship:______
Address ______Street City State Country Zip
Home Phone Number w/ Area Code:______Source: Fort Benning Rear Detachment SOP
E-Mail Address______
Native Language Spoken by Spouse/PNOK:______
Nearest Military Installation to Your Spouse/PNOK:______
7. Secondary Next Of Kin (SNOK)
Name:______Relationship: ______
Address ______Street City State Country Zip
Home Phone Number w/ Area Code:______
8. Evaluate potential family problems/concerns during your absence:
A. Special needs. Are there special needs in your family? Yes___ No___
If yes, state problem and assistance needed. ______
B. Financial. What arrangements have been make to provide financial support to spouse/children? Check to Bank (Sure Pay) ___ Allotment ___ Other ______
C. Housing. Will your family (spouse/children) relocate as a result of this deployment? Yes___ No___
If yes, relocation address: ______Street City State Country Zip
Phone Number w/ Area Code:______
If no, are there any concerns about current housing situations? Specify: ______
D. Transportation. Does your spouse/PNOK drive? Yes__ No__
E. Will reliable transportation be a problem during your absence? No___ Yes___
Explain______
F. List any other pertinent issues that will have an adverse affect on your deployment: ______
Signature: ______Date:______
Source: Fort Benning Rear Detachment SOP Family Readiness Group Information Sheet (Please fill in the applicable areas) PRIVACY ACT STATEMENT Authority: 10 U.S.C. Section 3010, 5 U.S.C. 522a Principle Purpose Information will be used to provide support, outreach and information to family members. Routine Uses: Primary Use of this information is to facilitate volunteers in providing command information to family members concerning unit events and in emergencies. Mandatory or Voluntary Disclosure: Voluntary
1. Sponsor’s name ______Unit ______Rank 2. Home address ______3. Home phone Work phone 4. Your name _____ Birthday _ Anniversary 5. Place of employment Work phone 6. Children’s names ______Age Birth date Age Birth date Age Birth date Age Birth date 7. Names of children’s schools ______8. Is your family expecting? If so, expected due date ______9. Please list any family members with special needs 10. Do you have a driver’s license? Yes ___ No ___ 11. What foreign languages do you speak? ______Your spouse? ______12. Other than your spouse, who would you notify in an emergency? (friend or neighbor) Name Relationship Phone Address 13. What are your hobbies and special interests? 14. When is the best time to call you? ______15. What topics would you like to discuss or hear about at a Family Readiness Group meeting? ______16. Could you help with any of the following? (Check any that apply.): FRG Activities Telephoning Fundraising Newsletter Baking Planning Other (Specify) 17. I give my permission to have my phone number published on the Family Readiness telephone contact roster. Yes______No______18. I understand that by checking the “yes” block above that my phone number will be published on the Family Readiness Group Contact Roster.
Your signature Date
Printed Name: ______