DEPARTMENT OF DEFENSE CHILD DEVELOPMENT PROGRAM
OMB No. 0704-0515
REQUEST FOR CARE RECORD
OMB approval expires
May 31, 2017
(Read Privacy Act Statement and Instructions on back before completing form.)
The public reporting burden for this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Information Management Division, 4800 Mark Center Drive,
Alexandria, VA 22350-3100 (0704-0515). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection
of information if it does not display a currently valid OMB control number.
PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION. RETURN COMPLETED FORM TO THE APPROPRIATE CHILD AND YOUTH PROGRAM
REPRESENTATIVE.
1. DATE OF REQUEST (YYYYMMDD)
2. EXPIRATION DATE (YYYYMMDD) (To be completed by Facility)
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)
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)
4. PROGRAM(S) DESIRED (X as applicable)
5. AGE GROUP (X one)
a. FULL-DAY CARE
d. FAMILY DAY CARE (FDC)
a. INFANTS (0 - 12 months)
b. PART-DAY CARE
e. PART-DAY ENRICHMENT
b. TODDLERS (13 - 35 months)
c. SCHOOL-AGE
f. PRE-SCHOOL
c. PRESCHOOL (3 - 5 years)
d. SCHOOL AGE (5+ years)
6. SPONSOR STATUS (X one)
a. SINGLE MILITARY
e. SINGLE DOD CIVILIAN
i. MILITARY/UNEMPLOYED SPOUSE
b. DUAL MILITARY
f. RETIRED MILITARY
j. MILITARY/OTHER THAN DOD SPOUSE
c. MILITARY/DOD SPOUSE
g. MILITARY RESERVE
k. OTHER (Specify)
d. DUAL DOD CIVILIANS
h. NATIONAL GUARD
7. PRESENT CHILD CARE ARRANGEMENTS (X as applicable)
a. FCC ON-INSTALLATION
d. CIVILIAN CDC
g. IN-HOME CARE
b. FCC OFF-INSTALLATION
e. MILITARY ALTERNATE CARE
h. NO PRESENT CARE
c. OTHER MILITARY CHILD
i. OTHER
f. NON-MILITARY ALTERNATE CARE
DEVELOPMENT CENTER (CDC)
(Specify)
8. GENERAL INFORMATION (X and complete as applicable)
a. IF CHILD IS NOT PRESENTLY IN CARE, IS EMPLOYMENT
c. IS CHILD ON OTHER MILITARY WAITING LIST?
YES
NO
YES
NO
OF SPOUSE IMPACTED? (If Yes, estimate average annual
(If Yes, name installation)
income lost)
b. HAS CHILD BEEN IDENTIFIED FOR SPECIAL NEEDS
d. CURRENT COST OF CARE PER WEEK
CARE?
(If child is currently in care)
9. ACCOMMODATION UPDATES/REVERIFICATION (For Office Use Only)
(1)
(2)
(3)
(4)
(5)
a. DATE CALLED
(YYYYMMDD)
b. DECLINED/
PLACED
c. COMMENTS/
INITIALS
d. PLACEMENT TIME
(In months)
DD FORM 2606, MAY 2014
PREVIOUS EDITION IS OBSOLETE.
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