NAVY EXCEPTIONAL FAMILY MEMBER (EFM)
RESPITE CARE WAITING LIST
CERTIFICATION AND INFORMATION FORM
After creating your MCC account and household profile, return the completed form to
NavyEFMPrespite@usa.childcareaware.org. You are not required to send in your EFMP Enrollment Letter.
*Sailor’s information listed below must match what was used to create the MCC account.
*Active Duty Sailor’s Name (First, Last): ____________________________________________________
Spouse Full Name (First, Last): _____________________________________________________________
(If other than spouse, please indicate status)
Sailor’s Contact Information
*Primary Phone #: _________________________________________________________________
*Primary Email: ___________________________________________________________________
Military Email (if not primary email): __________________________________________________
If Reservist, check here: ______
EFM child(ren) Information
(EFM child category information is found in the Navy Accountability and Assessment System [NFAAS])
EFM Child #1 Full Name: ____________________________________ EFM Category: _________
DoB (MM/DD/YYYY):___________
Eligibility for CYP EFM Respite Care
Sailor MUST be Active Duty or Reservist on Active Duty Orders (orders must be submitted)
Sailor MUST be enrolled in the Navy Exceptional Family Member Program with a child(ren)
assigned a Category 4 or 5 and residing with him/her in the same household
Eligible EFM child(ren) must be age birth through 18 years
Respite Care is authorized for the eligible EFM child(ren) only
By completing and submitting this form, I certify that my family meets the eligibility requirements for
Navy EFM Respite Care. I further understand that if my location/address or child’s EFM status changes, I
will update MCC as well as CCAoA. I acknowledge and understand my EFM child’s category and update
MUST BE CURRENT (HQ EFMP requires every 3 years) to accept enrollment once my family is offered a
space and the EFMP Enrollment Letter must be submitted at that time.
_________________________________________ _________________________
Sailor or Spouse Signature Date
click to sign
signature
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