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Paycare Program "Parent Promise" Form

  (To Complete with Every Pay Incentive " Request)

For long-term Consultative Services and to ensure that I meet my goal of continued access to "Pay Incentives" for my child(ren)'s  best

educational (birth to 12th grade), college , medical, transportation, and housing experience

Type of Pay Incentive:*

(Select All That Apply To Your Situation)

Your Email Address*

Number of Children*


Amount Requested:*

I Agree That I Understand The Following:*

(Check all boxes below)

If Full Amount Is Not Granted:*

(Select only the box which applies to your situation)

Statement of Agreement: *

I Choose Longer than my 12-month Membership Period:

(Periods beyond the 1-yr membership will result in a $100 Convenience Fee per additional year.)

E-Signature Disclosure*

(Check to agree to E-Sign this form.)


(Please E-sign Your Full Name)

Thank you! Your message was sent successfully and we will contact you in 24 to 48 business hours. Don't forget to complete links #1 and #2.

Welcome to Paycare Program!

Your "Parent Promise" form is the final step to begin processing your "Pay Incentive"!  Once we receive this form, along with the other 2 forms and attachments, our office goes to work on behalf of your family!  We do this by contacting who you want us to pay on your behalf and getting you processed! 

   You will hear from one of our

     agents within 24-48 hours

       via phone and/or email.


        Phone#: 336.897.3008.


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