Department of Defense Child Development Program
Request for Care Record
The 78th Services Division would like to welcome you to the Child Development Center &
Family Child Care.
1. Date of Request
//
Date of Request should be today's date. 		2. Expiration Date
 //
Expiration Date should be one year
from Date of Request.
3. Family Information
a. Sponsor's Name (Last, First, MI)
 b. Spouse's Name (Last, First, MI)
 
c. Child's Name (Last, First, MI)
 		 d. Childs Date of Birth
//
If your child is of school age,  please contact the Youth Center.  There is no waiting for the School Age Program. You may contact them at 926-2110. 		e. Child's Age
f. Home Address


g. Sponsor's Branch of Service
h. Duty Organization
i. Home Telephone Number
 		j. Duty Telephone Number
k. Sibling Care (Complete a separate form and list name and date of birth for each child requiring care)
(1) Name (2) Date of Birth (1) Name (2) Date of Birth
4. Program (s) Desired (Check All that Apply) 5. Age Group (Check One)
a. Full-Day Care
b. Part-Day Care
c. School-Age
d. Special Needs 		e. Family Day Care (FDC)
f. Part-Day Enrichment
g. Day Camp 		a. Infants (0-12 months)
b. Toddlers (13-35 months)
c. Preschool (3-5 years)
d. School Age (5+ years)
6. Sponsor Status (Check One)
a. Single Military
b. Dual Military
c. Military/DOD Spouse
d. Dual DoD Civilians 		e. Single DoD Civilian
f. Retired Military
g. Military Reserve
h. National Guard 		i. Military/Unemployed Spouse
j. Military/Other than DOD Spouse
k. Other (ex. Contractor)
     
7. Present child care arrangements (Check All that Apply)
a. FDC On-Installation
b. FDC Off-Installation
c. Other Military Child
         Development Center (CDC) 		d. Civilian CDC
e. Military Alternate Care
f. NON-Military Alternate
        Care 		g. In-Home Care
h. No Present Care
i. Other
    
8. General Information

Yes

No

Yes

No

a. If child is not presently in care,
    is employment of spouse
    awaited? (If Yes, estimate average
      annual income lost.)      

c. Is child on other military waiting
    list? (If Yes, name installation)
    

b. Has child been identified for
    special needs care?   		d. Current Cost of Care Per Week (If child is currently
      in care)          
9. E-Mail Address

Privacy Act Statement
Authority: PL 101-89 Sec. 1507; EO 9397.
Principal Purpose(s): To collect applicant information
for Child Development Programs and place applicants on
waiting lists for program services.  Information compiled
from applications is also used to assist management
determination of effectiveness of present and projection
of future program requirements. 		Routine Use(s):  None.
Disclosure:  Voluntary; however, failure to
furnish requested information will result in an
incomplete request for care record and possible
loss of placement on Child Development Program
waiting lists.


This form was developed from DD Form 2606 and contains all
fields necessary for placement in the
Child Development Program or waiting list.
All questions should be directed to
Vera Keasley, Coordinator,
 Family Child Care

This site is maintained by Elizabeth Shedd
78 MSG/SVK Commercial (478) 926-6153 or DSN 468-6153