If you
would like assistance locating child care, please fill out this
form.
*Service Members
Name:
*Contacts
Name:
*Address:
*City:
*State:
*Zip:
*Do you
receive state assistance?
*Branch and Duty Station:
*Rank/Rate:
*Phone (with area code):
*Email
Address (mandatory):
:
*Childs Name - Child #1:
*Birth Date:
*Have you placed your child on the base child care center's wait list?
If not why?:
Out of School Area
Special Needs
Other - Please Specify
Date
Care Needed:
Preferred Type of Care (select all that
apply):
Child
Care Center
Family Child
Care Provider
Nursery/Preschool
School-Age Care
Please enter the name of your elementary
school (if applicable):
*Drop
Off Time:
*Pick Up
Time:
*Days:
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Additional requirements/ desired location:
Childs Name - Child #2:
Birth date :
Date
Care Needed:
Preferred Type of Care (select all that
apply):
Child
Care Center
Family Child
Care Provider
Nursery/
Preschool
School Age
Care
*Please enter the name of your elementary
school (if applicable):
*Drop
Off Time:
*Pick Up
Time:
*Days:
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Other Children, please include all previous information :
How did you hear about us :
Thank
you for taking the time to complete this form. Please click the Submit
Form button to send us your information. We will be contacting you
soon.
Contact
info:
1-800-300-1247
