Military Child Care Request Form

If you would like assistance locating childcare, please fill out and submit this form.
Required fields are marked with an *

GENERAL INFORMATION
Service Member's Name*
Contact's Name*
Address*
City*
State*
Zip*
Phone*
E-Mail Address*
Do you receive state assistance?* Yes No
Branch and Duty Station*
Rank/Rate*

CHILD #1
Child's Name*
Birthdate*
Have you placed your child on the base childcare center’s wait list?* Yes No
If not, why?	Out of School area Special needs Other (explain):
Date Care is Needed
Preferred Type of Childcare	Child Care Center Family Childcare Provider Nursery/Preschool School Age Care
Elementary School (if applicable)
Drop Off Time*
Pick Up Time*
Days Needed* Sun Mon Tue Wed Thu Fri Sat
Additional requirements / desired location / special needs

CHILD #2
Child's Name
Birthdate
Have you placed your child on the base childcare center’s wait list? Yes No
If not, why?	Out of School area Special needs Other (explain):
Date Care is Needed
Preferred Type of Childcare	Child Care Center Family Childcare Provide Nursery/Preschool School Age Care
Elementary School (if applicable)
Drop Off Time
Pick Up Time
Days Needed Sun Mon Tue Wed Thu Fri Sat
Additional requirements / desired location / special needs

OTHER INFORMATION
For additional children, list name, birthdate, and hours & days of care needed
How many people are in your family?
How did you hear about us?

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