Form Navmc 11654 – Fill Out and Use This PDF

NAVMC 11654 (5-09) (EF)

FOUO - Privacy Sensitive when filled in.

Unit, Personal and Family Readiness Program Authorization

This Authorization is solely for use by the Unit, Personal and Family Readiness Program (UPFRP) and is not to be confused with the Record of Emergency Data (RED). While information provided may be the same for both the UPFRP Authorization and the RED, the RED is the official record and will be referred to for all official communication outside the parameters of the UPFRP, e.g. casualty notification.

PRIVACY ACT STATEMENT

AUTHORITY: 10 USC 5013; EO 9397; 10 USC 5041 PRINCIPAL PURPOSE(S): To obtain required information for sponsors, spouses and designated contacts for the identified Unit, Personal and Family Readiness Program to enable the unit Commander and designated staff members and authorized volunteers to communicate in an accurate, rapid, and efficient manner with sponsor, spouse and Designated Contacts on matters relating to their Unit, Personal and Family Readiness Program. Access to personally identifiable information contained on data sheets will be on an official "need to know" basis and granted only to authorized persons with current certificates showing completion of requisite Personally Identifiable Information Training.

ROUTINE USES(S): None.

DISCLOSURE: Participation is mandatory for sponsors. Sponsors must provide a primary and secondary contact path. It is also mandatory for married sponsors to provide a primary contact path for spouse or a signed Opt-out Form should the spouse choose not to participate. For military personnel, generally MCO 1754.9, chapter 2, paragraph 3. m and specifically chapter 4, paragraph 2.a(2)(3) are lawful orders and are punitive in nature. Violations may result in disciplinary action under Article 92 of Uniform Code of Military Justice, and/or other adverse administrative action. It is not mandatory for single sponsors to provide required information for anyone other than themselves. All designated contacts must be over the age of 18 with the exception of a spouse. The current Unique ID, "Last Name, Last Four" is required as it is essential to identify the sponsor and his/her designated contacts.

Sponsor Name :

Unit :

Family Readiness Officer :

Instructions :

I hereby authorize the unit commander and designated members of the unit's Family Readiness Command Team, to include but not limited to, the unit Family Readiness Officer (FRO) and designated UPFRP Volunteers to communicate with my spouse*, and individuals I have listed below, hereinafter referred to as "Designated Contacts" on matters pertaining to the UPFRP. Designated Contacts must be 18 years of age or older, with the exception of a spouse.

*Designated Contact #1 :

*It is mandatory for spouses to be listed as Designated Contact #1 for married sponsors or submit a signed Opt-Out Form.

Designated Contact #2:

Designated Contact #3:

Designated Contact #4:

Communication will be in compliance with Marine Corps Order 1754.9, Unit, Personal and Family Readiness Program, and deemed by the unit commander to be relevant, appropriate and in accordance with his vision and intent for his UPFRP.

The UPFRP may use the Mass Communication Tool as one method of effecting clear and direct communication on matters pertaining to personal and family readiness (readiness and deployment support, information and referral and official command communications) between the sponsor, spouse* and Designated Contacts. (DoN Systems of Record Notice M01754-5)

The UPFRP will use the Volunteer Tracking Tool as one method of effecting clear and direct communication on matters pertaining to volunteer opportunities. (DoN Systems of Record Notice NM01754-2)

Sponsor Signature :

Sponsor Name :

Rank :

Sponsor Initial

1 OF 4

FOR OFFICIAL USE ONLY.

Adobe Designer 8.0

Unit, Personal and Family Readiness Program Authorization

Sponsor Name :

Unit :

Family Readiness Officer :

Instructions :

All Sponsors: All Sponsors are required to provide LAST NAME, FIRST NAME, LAST 4 OF SSN, BIRTHDATE, ONE PRIMARY CONTACT PATH AND ONE SECONDARY CONTACT PATH to enable reliable and timely delivery of communication from the command. The Sponsor may choose from any of the available delivery paths listed below. Standard text messaging charges will apply.

Designated Contacts must be 18 years of age or older, unless a spouse. Ensure information is complete.

Single Sponsors : Designated Contacts are optional.

Married Sponsors : Spouse* shall be entered as Designated Contact #1. One primary contact path and one secondary contact path to enable reliable and timely delivery of communication from the command to the spouse is required unless/until a signed Opt-Out Form is on file with the unit.

(*Spouse has the right to Opt-Out; however, information for the spouse is required until an Opt-Out Form with signatures is submitted

to the unit at which time the information for the spouse will be deleted. Opting out is not a recommended course of action due to the benefits of receiving official communication, information and referral services from the UPFRP. Should the Spouse Opt-Out, all family readiness communication from the command including deployment-related communications, will be the responsibility of the sponsor.)

Language Codes : A Code other than E (English) will alert the FRO that the Designated Contact is not fluent or may have difficulty understanding communications in English. There is no guarantee that translation will be available should another language code be provided.

E=English S=Spanish (Europe or Latin America) J=Japanese F=French I=Italian P=Portuguese

S=Spouse *C=Child P=Parent *F=Family member or other contact

Sponsor Information (Mandatory) For military personnel, generally chapter 2, paragraph 3.m and specifically chapter 4, paragraph 2.a(2) of MCO 1754.9 are lawful orders and punitive in nature. Violations may result in disciplinary action under Article 92 of the Uniform Code of Military Justice and/or other adverse administrative action. REQUIRED: LAST NAME, FIRST NAME, SSN (LAST 4), DATE OF BIRTH, PRIMARY/SECONDARY PATHS OF CONTACT

UIC

Last Name

First Name

MI SSN (last 4)

Address

Apt No.

Date of Birth (MM/DD/YYYY)

City

State

Zip

Country

Work E-Mail Address

Home E-Mail Address

Alternate E-Mail Address

Work Cell Phone

Personal Cell Phone

Work Phone

Ext.

Home Phone

SMTP Text Device (email address-standard texting charges will apply)

SMS SMPP Text Device (telephone #-standard texting charges will apply)

Language

2 OF 4

Sponsor Initial

FOR OFFICIAL USE ONLY.

Unit, Personal and Family Readiness Program Authorization

Sponsor Name :

Unit :

Family Readiness Officer :

Designated Contact #1

It is mandatory for married sponsors to provide required information for their spouse as Designated Contact #1 unless/until an Opt-Out Form with signatures is submitted to the unit at which time the information for the spouse will be deleted. REQUIRED: LAST NAME, FIRST NAME,

PRIMARY/SECONDARY PATH OF CONTACT

Last Name

First Name

MI

Contact Code

Address

Apt No.

City

State

Zip

Country

Work E-Mail Address

Home E-Mail Address

Alternate E-Mail Address

Work Cell Phone

Personal Cell Phone

Work Phone

Ext.

Home Phone

SMTP Text Device (email address-standard texting charges will apply)

SMS SMPP Text Device

Language

Designated Contact #2 - OPTIONAL FOR ALL SPONSORS/ PERSON LISTED MUST BE 18 YEARS OF AGE OR OLDER

Last Name

First Name

MI Contact Code

Address

Apt No.

City

State

Zip

Country

Work E-Mail Address

Home E-Mail Address

Alternate E-Mail Address

Work Cell Phone

Personal Cell Phone

Work Phone

Ext.

Home Phone

SMTP Text Device (email address-standard texting charges will apply)

SMS SMPP Text Device

Language

Sponsor Initial

3 OF 4

FOR OFFICIAL USE ONLY.

Unit, Personal and Family Readiness Program Authorization

Sponsor Name :

Unit :

Family Readiness Officer :

Designated Contact #3 - OPTIONAL FOR ALL SPONSORS/ PERSON LISTED MUST BE 18 YEARS OF AGE OR OLDER

Last Name

First Name

MI Contact Code

Address

Apt No.

City

State

Zip

Country

Work E-Mail Address

Home E-Mail Address

Alternate E-Mail Address

Work Cell Phone

Personal Cell Phone

Work Phone

Ext.

Home Phone

SMTP Text Device (email address-standard texting charges will apply)

SMS SMPP Text Device

Language

Designated Contact #4 - OPTIONAL FOR ALL SPONSORS/ PERSON LISTED MUST BE 18 YEARS OF AGE OR OLDER

Last Name

First Name

MI Contact Code

Address

Apt No.

City

State

Zip

Country

Work E-Mail Address

Home E-Mail Address

Alternate E-Mail Address

Work Cell Phone

Personal Cell Phone

Work Phone

Ext.

Home Phone

SMTP Text Device

SMS SMPP Text Device (telephone #-standard texting charges will apply)

(email address-

Language

Sponsor Initial

4 OF 4

FOR OFFICIAL USE ONLY.