Department Of Defense Child Development Program - Request For Care Record - Dd Form 2606

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DEPARTMENT OF DEFENSE CHILD DEVELOPMENT PROGRAM
REQUEST FOR CARE RECORD
PRIVACY ACT STATEMENT
PL 101-89 Sec. 1507; EO 9397.
ROUTINE USE(S): None.
AUTHORITY:
To collect applicant information for Child
DISCLOSURE: Voluntary; however, failure to furnish requested
PRINCIPAL PURPOSE(S):
Development Programs and place applicants on waiting lists for
information will result in an incomplete request for care record and
program services. Information compiled from applications is also
possible loss of placement on Child Development Program waiting
used to assist management determination of effectiveness of
lists.
present and projection of future program requirements.
1. DATE OF REQUEST
(YYYYMMDD)
2. EXPIRATION DATE
(YYYYMMDD)
3. FAMILY INFORMATION
a. SPONSOR'S NAME
(Last, First, Middle Initial)
b. SPOUSE'S NAME
(Last, First, Middle Initial)
c. CHILD'S NAME
(Last, First, Middle Initial)
d. CHILD'S DATE OF BIRTH
(YYYYMMDD)
e. CHILD'S AGE
f. HOME ADDRESS
(Street, City, State, Zip Code)
g. SPONSOR'S BRANCH OF SERVICE
h. DUTY ORGANIZATION
i. HOME TELEPHONE NUMBER
(Include Area Code)
j. DUTY TELEPHONE NUMBER
(Include Area Code)
(Complete a separate form and list name and date of birth for each child requiring care)
k. SIBLING CARE
(2) DATE OF BIRTH
(2) DATE OF BIRTH
(1) NAME
(Last, First, Middle Initial)
(1) NAME
(Last, First, Middle Initial)
(YYYYMMDD)
(YYYYMMDD)
(X as applicable)
(X one)
4. PROGRAM(S) DESIRED
5. AGE GROUP
(0 - 12 months)
a. FULL-DAY CARE
a. INFANTS
e. FAMILY DAY CARE (FDC)
b. PART-DAY CARE
f. PART-DAY ENRICHMENT
b. TODDLERS
(13 - 35 months)
c. SCHOOL-AGE
g. DAY CAMP
c. PRESCHOOL
(3 - 5 years)
d. SPECIAL NEEDS
d. SCHOOL AGE
(5+ years)
(X one)
6. SPONSOR STATUS
a. SINGLE MILITARY
e. SINGLE DOD CIVILIAN
i. MILITARY/UNEMPLOYED SPOUSE
b. DUAL MILITARY
f. RETIRED MILITARY
j. MILITARY/OTHER THAN DOD SPOUSE
k. OTHER
(Specify)
c. MILITARY/DOD SPOUSE
g. MILITARY RESERVE
d. DUAL DOD CIVILIANS
h. NATIONAL GUARD
7. PRESENT CHILD CARE ARRANGEMENTS
(X as applicable)
a. FDC ON-INSTALLATION
d. CIVILIAN CDC
g. IN-HOME CARE
e. MILITARY ALTERNATE CARE
h. NO PRESENT CARE
b. FDC OFF-INSTALLATION
l. OTHER
(Specify)
c. OTHER MILITARY CHILD
f. NON-MILITARY ALTERNATE
DEVELOPMENT CENTER (CDC)
CARE
8. GENERAL INFORMATION
(X and complete as applicable)
c. IS CHILD ON OTHER MILITARY WAITING LIST?
YES
NO
a. IF CHILD IS NOT PRESENTLY IN CARE, IS EMPLOYMENT
YES
NO
(If Yes, estimate average annual
(If Yes, name installation)
OF SPOUSE AWAITED?
income lost)
(If child is currently in care)
d. CURRENT COST OF CARE PER WEEK
b. HAS CHILD BEEN IDENTIFIED FOR SPECIAL NEEDS
CARE?
9. UPDATE REQUIRED PER INSTRUCTIONS
(For Office Use Only)
(1)
(2)
(3)
(4)
(5)
a. DATE CALLED
(YYYYMMDD)
b. DECLINED/
PLACED
c. COMMENTS/
INITIALS
d. PLACEMENT TIME
(in months)
Designed using PureEdge ICS Viewer, AFDPO/PPPF,
PREVIOUS EDITION MAY BE USED.
DD FORM 2606, JUL 1998 (EG)
(IMT-V1)
Sep 03, Exception approved by ...................................

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