Dd Form 2606 - Department Of Defense Child Development Program Request For Care Record Page 2

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PRIVACY ACT STATEMENT

AUTHORITY: 10 U.S.C. 3013, Secretary of the Army; 10 U.S.C. 5013, Secretary of the Navy; 10 U.S.C. 5041, Headquarters, Marine Corps; 10

U.S.C. 8013, Secretary of the Air Force; DoD Instruction 6060.02, Child Development Programs; Army Regulation 608-10, Child Development

Services; OPNAV Instruction 1700.9 series, Child and Youth Programs; Marine Corps Order P1710.30E, Children, Youth, and Teen Program

(CYTP); Air Force Instruction 34-248, Child Development Programs; and Air Force Instruction 34-249, Youth Programs, and 34-276, Family Child

Care.

PRINCIPAL PURPOSE(S): To collect applicant information for Child Development Programs and establish waiting lists for program services.

This information may also be used for statistical analysis, tracking, reporting, and evaluating program effectiveness. When completed, records are

covered by one of the appropriate SORNS:

Department of the Army:

Department of the Navy:

Department of the Air Force:

ROUTINE USE(S): Department of the Army records may be disclosed to civilian health and welfare departments/agencies in emergencies.

Department of the Navy records may be disclosed to local, state and Federal officials involved in child care services, if required, in the

performance of their official duties relating to child abuse reporting and investigations. Department of the Air Force records may be disclosed to

civilian health and welfare departments/agencies in emergency situations.

DoD Blanket Routine Uses 1 (Law Enforcement), 4 (Congressional Inquiries), 6 (Required by International Agreement), 9 (Department of Justice

for Litigation), 12 (National Archives and Records Administration), and 15 (Data Breach Remediation) specifically apply to this system. Other DoD

Blanket Routine Uses found at may apply to these records. Any release

under a blanket routine use will be compatible with the purpose of the collection.

DISCLOSURE: Voluntary; however, if you fail to furnish the needed information, you might not be added to a waiting list or notified when there is

space for your child.

INSTRUCTIONS

This form is to be completed by authorized patrons (per Department of Defense Instruction 6060.02, Child Development Programs) and serves as

the Official Request for Care for use of Department of Defense operated Child Development Programs. Providing this information is voluntary, but

failure to complete the form may result in a denial of care.

1. Provide the date the request is completed.

2. To be completed by facility where care is requested. This form expires one year from the initial date of request.

3. Family Information.

3.a. Provide the sponsor’s last name, first name and middle initial.

3.b. Provide the spouse’s last name, first name and middle initial (when applicable).

3.c. Provide the last name, first name and middle initial of the child for whom care is being requested.

3.d. Provide the date of birth of the child for whom care is being requested.

3.e. Provide the age of the child for whom care is being requested at the time of application.

3.f. Provide the residential address of the child for whom care is being requested.

3.g. Provide the sponsor’s branch of service. For DoD civilians, provide the service or agency of employment. If this is not applicable, enter NA.

3.h. Provide the organization to which the sponsor is employed. If this is not applicable, enter NA.

3.i. Provide the home telephone number of the sponsor.

3.j. Provide the work telephone number of the sponsor.

3.k. If the family is requesting care for additional children, enter their last name, first name, middle initial and date of birth, and complete a

separate form for each child when applicable.

4. Program(s) Desired.

- Place an “X” to indicate the family's desire for where the child’s need for care may be accommodated.

5. Age Group.

- Place an “X” to indicate the age group that the child falls on the date of application.

6. Sponsor Status.

- Place an “X” to indicate the status of the sponsor on the date of application.

- For “Other”, specify the sponsor’s status.

7. Present Child Care Arrangements.

- Place an “X” to indicate the present arrangement for child care of the child for whom care is being requested.

- For “Other”, specify the sponsor’s status.

8. General Information.

8.a. Indicate “Yes” or “No” if the lack of child care is impacting the ability of the spouse (where applicable) to find employment.

8.b. Indicate “Yes” or “No” if the child has been identified for special needs care.

8.c. Indicate “Yes” or “No” if the child is on other military waiting lists for child care. If, “yes”, provide the name of the installation where the child

is on a waiting list.

8.d. If the child is currently accommodated in non-DoD child care, indicate the weekly cost for care.

9. To be completed by the facility only.

DD FORM 2606 (BACK), MAY 2014