Online Application

Trustworthy Online Application

Thank you for your interest in Trustworthy Afterschool Care. To complete the application process, please fill out the form below. Please note that your application is not considered complete until you have submitted the $25 non-refundable registration fee via Cash App or Venmo.

We appreciate your understanding and cooperation in submitting the registration fee to secure a spot for your child in our program. Should you have any questions or encounter any issues during the application process, please don’t hesitate to reach out to us. We look forward to providing reliable and quality afterschool care for your child.

Cash App: $trustworthyac

Venmo: @trustworthyas

Online Application

Child's Information

Child's First Name

Child's Middle Name

Child's Last Name

Child's DOB

Child's Gender

Child's Race

Grade in Fall 2023

School

1st Parent/Guardian Information

First Name

Middle Name

Last Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Cell or Home Number

Work Number

Email (This is how we will communicate program information.)

2nd Parent/Guardian Information

First Name

Middle Name

Last Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Cell or Home Number

Work Number

Emergency Information

If this section does not apply to you, please disregard.

Known Allergies:

Medications or Medical Concerns

Emergency Contacts

If parents cannot be reached, who else should we notify?

Emergency Contact First Name

Emergency Contact Last Name

Relationship to child

Phone Number

First Name

Last Name

Relationship to child

Phone Number

Is there anyone court-ordered that is NOT authorized to visit or pick up your child?

If this does not apply to you, please disregard.

First Name

Last Name

Relationship to child

First Name

Last Name

Relationship to child

Please read and check the boxes below concerning waivers and agreements

I hereby release and discharge Trustworthy Afterschool Care, its agents, volunteers, and employees from all claims of injury, illness, death, loss, or damage that my child/ren may suffer because of participation.

It is my complete understanding that if I wish to terminate this program or change my method of payment in any way, I must give Trustworthy Afterschool Care a two-week written cancellation or change notice prior to the week of the payment date.

I permit Trustworthy Afterschool Care to use images of my child as a Trustworthy Afterschool Care participant in internal and external promotional materials, including printed material, broadcast advertising, promotional videos, and the Trustworthy Afterschool Care website.

Parent/Legal Guardian Signature: (type your name)