Defense Logistics Agency Child Development Services Request . For Care Record
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DEFENSE LOGISTICS AGENCY CHILD DEVELOPMENT SERVICES REQUEST FOR CARE RECORD
PRIVACY ACT STATEMENT
AUTHORITY:
PL 101-89 SEC 1507;EO 9397
PRINCIPLE PURPOSE(S): To collect applicant information for Child Development Services and place applicants on waiting lists for program
services. Information compiled from applicants is also used to assist in 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 Services waiting lists.
1. DATE OF REQUEST (MMDDYYYY)
2. EXPIRATION DATE (MMDDYYYY)
3. TODAY'S DATE
5 ID CARD CHECKED
6 FORM CHECKED (sps only)
7 DATE REC'D
8 MAILED/FAXED
4. PRIORITY
YES
NO
9. FAMILY INFORMATION
a. SPONSOR'S NAME (Last, First, MI)
b. SPOUSE'S NAME (Last, First, MI)
c. SPONSOR'S RANK/GRADE
d. SPOUSE'S RANK/GRADE
e. ORGANIZATION
f. ORGANIZATION
h. SPOUSE'S WORK NUMBER (Include Area Code)
g. SPONSOR'S WORK & HOME NUMBERS
i. HOME ADDRESS (Street, City, State, Zip Code)
k. DATE OF BIRTH (MMDDYYYY)
l. AGE
j. CHILD'S NAME (Last, First, MI)
10. PROGRAMS DESIRED (''X'' If applicable)
11. AGE CATEGORY (''X'' One)
A. FULL DAY
INFANTS (0-18 MOS.)
B. PART DAY
TODDLER (18-36 MOS.)
C. SCHOOL AGE
PRESCHOOL (3-5 YEARS)
D. HOURLY CARE
SCHOOL AGE (5+ YEARS)
12. SPONSOR/SPOUSE STATUS (''X'' One)
SINGLE MILITARY
DUAL DOD CIVILIANS
MILITARY/OTHER THAN DOD SPOUSE
DUAL MILITARY
SINGLE DOD CIVILIAN
DOD/UNEMPLOYED SPOUSE
DOD/NON-DOD SPOUSE
MILITARY/DOD SPOUSE
MILITARY/UNEMPLOYED SPOUSE
13. PRESENT CHILD CARE ARRANGEMENTS (''X" One, Complete as Applicable)
FCC ON INSTALLATION
CIVILIAN CDC
IN YOUR HOME (i.e. nanny)
FCC OFF INSTALLATION
MILITARY ALTERNATE CARE
NO PRESENT CARE (home w/ parent)
NON-MILITARY ALTERNATE CARE
SELF-CARE (home w/ no supervision)
MILITARY CDC
14. GENERAL INFORMATION (''X'' One, Complete as Applicable)
If Yes, estimate annual income lost:
a. If your child is not enrolled in care, is employment of spouse awaited?
Yes
No
No
b. Does your child have any on-going medical concerns?
Yes
c. Has your child been identified for special needs care?
Yes
No
d. Is your child on another military waiting list?
If Yes, name Installation:
Yes
No
e. Total Family Income (Sponsor & Spouse):
15. UPDATE REQUIRED PER INSTRUCTIONS (For Office Use Only)
(1)
(2)
(3)
(4)
(5)
a. DATE CALLED
(MMDDYYYY)
b. DECLINED/
PLACED
c. COMMENTS/
INITIALS
d. PLACEMENT TIME
(In Months)
STATEMENT OF UNDERSTANDING
I UNDERSTAND THAT I MUST CONTACT CIDS AT A MINIMUM OF EVERY 3 MONTHS TO CONFIRM MY INTEREST IN REMAINING ON THE
WAITING LIST. CHECKING A CHILD'S STATUS ON WAITING LIST IS NOT THE SAME AS UPDATING. PATRONS WILL BE REMOVED
WITHOUT NOTICE WHEN THE QUARTERLY UPDATE IS PAST DUE.
SPONSOR'S SIGNATURE
DATE SIGNED
P.O.A. VERIFIED (sps only)
DLA FORM 24, MAY 1999 (EG)
PDF (DLA)
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