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Frg survey
- 1. Delaware Family Readiness Group Family Information Survey Please complete This information will be used for FRG purposes only. Soldiers Name ___________________________ Rank _______ Birth Date ________________________ Soldiers Battalion/Company__________________ Last four of SSN____________ Work Phone ______________________ Spouse’s Name ____________________ Spouse’s Birth Date _______________ Home Address __________________________________________________________ Spouses Email Address ____________________________________________________ Home Phone _________________ Cell Phone______________ Anniversary _______________ Spouse’s Place of Employment____________________________________________________ Print Children(s) names 1) _____________________________________________ Birth Date ____________ 2) _____________________________________________ Birth Date ____________ 3) _____________________________________________ Birth Date ____________ 4) _____________________________________________ Birth Date ____________ Are you expecting a baby? Y N If Yes what is the Due Date?____________________ A vehicle is available to family.___ Yes___ No I use public transportation as my primary source of travel. ___ Yes ___ No English is my second language. My language of origin is: _______________________________________________ Other family members living with us: _______________________________________________________________ Special needs family members: ____________________________________________________________________ Religious Preference_____________________________________________________________________________ Pet Information_________________________________________________________________________________ In case of emergency, in addition to the Soldier, you should notify: (this is someone for support of the Spouse)_______________________________________________________________________________________ I am interested in assisting other family members by being a part of a FRG. ___ Yes___ No YES NO N/A May we include your names in our newsletter during your birthday month? May we include your names in our newsletter during the month of your anniversary? Is the sponsor interested in volunteering? Is the spouse interested in volunteering? Are any of your children interested in volunteering? Do any of your children baby-sit? If you have children who baby-sit would they be interested in having their name on a roster? Are they certified? If no, would they be interested in attending a certification class? -PLEASE TURN OVER-
- 2. If you are interested in volunteering, what area(s) would you like work in? Point of Contact Newsletter Volunteer Coordination Fund-Raiser Planning Event/Activity Planning Welcome Committee Morning Bake Sales Lunch Bake Sales Baking Sponsorship Administrative/Treasurer Children's Activities Other areas: Skills and talents that I would be willing to share with a small group are: __________________________________________________________________________________________________ __________________________________________________________________________________________________ __ How often would you like the FRG to meet? __ Times/Month __ Monthly __Quarterly __ Every Other Month When would you like the FRG to meet? __ Day __ Evening __Weekday __ Weekend Program, or subjects, that I would be interested in learning more about are: ___ Health/First Aid Training ___ A Day in the Field ___ Community Resources ___ Coping with Separation ___ New Parent Program ___ Army Family Team Building classes ___ Stress Management ___ Self-development ___ Financial Planning ___ Emergency Planning ___ Military Pay/Benefits ___ Spouse Employment ___ Relocation Planning ___ Educational Opportunities ___ Army Community Service (ACS) ___ Volunteer Opportunities ___ Youth Activities ___ Recreational Information Trips or activities that I would be interested in are: __________________________________________________________________________________________________ What are your expectations of your FRG? __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ ___ I give my express permission to my or my spouse’s Family Readiness Group to contact or notify me regarding FRG and Unit information and activities. YES ________ NO _________ ______________________________________________________________________________ Spouse’s Signature Date _________________________________________________________________ Soldier’s Signature Date Privacy Act Statement Authority: 10 U.S.C., Section 3013 Principal Purpose: Information will be used to provide support, outreach and information to family members prior to and during periods of family separations.
- 3. Routine Uses: None Mandatory or Voluntary Disclosure and Effect on Individual Not Providing Information: Disclosure is voluntary. Nondisclosure could affect the speed in which necessary services are provided to the family member by community resource agencies.