Kadena Air Force Base Military and Family Readiness Center (M&FRC)

Client Information and Service Delivery Statement of Understanding (SOU)(Good for 1 year)
MILITARY MEMBER INFORMATIONNAME (First, Middle, Last)
SEXMARITAL STATUS

GRADE
DATE OF BIRTHHOME ADDRESS (Include Zip Code)

DoD ID:LAST 4 SSN

STATUSUNITPERSONAL PHONE

BRANCH OF SVC
BASEWORK PHONEEMAIL ADDRESS

Purpose of Visit (Circle One): Personal Financial Management - Employment Assistance - Transition - Emergency Financial AidFamily Life - Relocation - Family Readiness - Volunteer Program - EFMP - Cultural Awareness – Deployment - Other

SPOUSE/NOK INFORMATIONNAME (First, Middle, Last)

LAST 4 SSN

E-MAIL ADDRESSADDRESS (if different than military member)PERSONAL PHONE

MINOR CHILDREN
Name(s)Date of BirthName(s)Date of Birth

PRIVACY ACT STATEMENTAUTHORITY: 10 U.S.C. 8013 and Executive Order 9397
PRINCIPAL PURPOSE: Client demographics are required for accurate service delivery, analysis, and future program planning.
ROUTINE USES; This information may be disclosed to federal, state, local or foreign law enforcement authorities for investigating or prosecuting a violation or potential violation oflaw; to federal, state, or local agencies to obtain information concerning hiring or retention of an employee, issuance of other benefit; to congressional office in response to their inquiry
made at the request of the individual; to the Office of Management and Budget in connection with review of private relief legislation as set forth in OMB Circular A-19; to NARA forrecords management inspections: and to the Department of Justice for pending or potential litigation.
DISCLOSURE IS VOLUNTARY: Failure to provide the necessary data will not result in the individual being denied services.

Demographics and Services: You are being asked to provide information for secure storage in our Air Force Family
Integrated Results and Statistical Tracking (FIRST) system. Your record contains demographic information, a brief description ofyour visit(s), and information regarding your service plan. Records are maintained for the sole purpose of continued service to you.
Privacy and Disclosure: The A&FRC respects your right to privacy, however, the staff members DO NOT have privilegedcommunication. If your supervisor, Commander, or First Sergeant made your appointment for you, we may provide them general
feedback about the consultation, but normally will not go in to specific details. Air Force policy requires any A&FRC staff to contact
proper authorities regarding any statement made or information disclosed if it pertains to possible violations to AFI 40-301 (FamilyAdvocacy Program) or admission of a crime in violation of the Uniformed Code of Military Justice, federal, or state law(s).
Minor Children Clause: By signing this form, you grant permission for your minor child to participate in our services and/oractivities. You agree to and shall indemnify and hold harmless the A&FRC, its offices, agents, and employees, from and against any
and all claims, losses, damages, causes of action, suits, and liability of every kind; including all expenses of litigation, court costs, andattorney’s fees, for any injury or damages which you, your child, or any other person or entity might sustain as a result of your childparticipating in a service/activity.
Photographs: Please be aware that photographs may be taken for use in promoting our programs and events. The photographs
may be used in various media outlets, including (but not limited to) internet, publications, and social media. If you do not want yourpicture taken or shared, PLEASE INFORM A STAFF MEMBER DURING THE EVENT IN WHICH PHOTOGRAPHS ARE
BEING TAKEN.
By signing below, you are acknowledging you have read and understand the above information.

Customer Signature

Updated 7 Apr 20

Date

A&FRC Consultant Signature

DatePersonal Readiness Inventory
Name: _____________________________

Sponsors Last 4: _________

Date: _________

Please answer this brief inventory, it helps us understand your overall personal readiness and adjustment tomilitary life. Instructions: Based on the past week please rate how well things are going by placing a hash mark on
the 0-10 scales below, with 10 as the best possible rating. Your consultant will use your answers to clarify yourgoals for coming to the Airman and Family Readiness Center.
OVERALL ADJUSTMENT TO MILITARY LIFE
(Understand & support the military lifestyle & mission requirements, etc…)

0RELOCATION/MOVING(Ability to move when required)0
ADJUSTMENT TO COMMUNITY(Ability to find on/off-base information, services, events & activities, etc…)

0
DEPLOYMENT READINESS(Ability to support short-notice deployments, awareness of available support for loved ones, etc…)

0
EMPLOYMENT(Job search techniques & skills, ability to secure suitable employment, etc…)

0
FINANCIAL READINESS(Basic needs & financial obligations met, savings, investments & retirement, etc…)

0
MILITARY/WORK ENVIRONMENT(Work environment/relationships OPSTEMPO/pace of work)

0
PERSONAL RELATIONSHIPS(Family, Friends, & loved ones etc…)

0RETENTION(Intention to continue military career past current commitment)

0
TRANSITION TO CIVILIAN LIFE
(Prepared for separation/retirement, aware of benefits & entitlements, etc.)0

The information herein is FOR OFFICIAL USE ONLY (FOUO) information which must be protected under the Freedom ofInformation Act (5 U.S.C. 552) and/or the Privacy Act of 1974 (5 U.S.C. 552a). Unauthorized disclosure or misuse of thisPERSONAL INFORMATION may result in disciplinary action, criminal and/or civil penalties.