Hearts Connected Affiliate Network Application Form

Thank you for your interest in joining our network!

Please allow up to 3 business days to hear back from us via email.

Are you requesting to join the network as a:

Independent Contractor (1099)Legal Entity ( i.e. LLC)Unsure, would like to discuss

Legal Name:*

First NameLast Name

Nickname/Preferred Name

Business Name (if applicable)

Phone Number:*

Area CodePhone Number

E-mail Address:

Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Address Type

HomeBusinessBoth, home and business

How did you hear of us?*

Others:

Upload Resume:

Upload a File

REQUIREMENTS

I acknowledge that I meet all of the following requirements needed for my application to be conditionally approved:

A current Certified Child Life Specialist

Have paid clinical experience for three or more years

Have home office accessibility and willing to provide virtual services.

Able to provide in person visits within a 30 mile radius.

Understand that if accepted I will be a 1099 contractor and that I must supply my own liability insurance.

I reviewed a copy of the contract. Once reviewed, I will confirm understanding of agreement and sign it via DocuSign.

HCAN Contract

Briefly describe your background and interest in joining Hearts Connected Affiliate Network:*

Certifications and training that you have attended/completed within the last 2 years:

References

Please list two (2) references that are familiar with your work life.

Reference 1

Name:*

First NameLast Name

Phone Number*

Area CodePhone Number

Years Known:*

Professional Relationship:

Email

example@example.com

Referral Consent

Referral is aware of your application and is expecting to be contacted.

Reference 2

Name:*

First NameLast Name

Phone Number*

Area CodePhone Number

Years Known:*

Email

example@example.com

Referral Consent

Referral is aware of your application and is expecting to be contacted.

Services Requesting*

Join Network! Start up fee -$1,500.00

One time fee that includes all basic services. Includes 2 hour on-boarding support for business development. An additional $50/month and 10% of session billing will be collected after 30 days to cover business expenses, monthly support, and network membership.

Social Media Assessment- Expansive$800.00

Review of your existing Facebook, LinkedIn and Instagram accounts, advising on how to improve your platform to enhance business

Website Development on Wix$800.00

Work with you to build a business website on Wix. This is in addition to the landing page provided with Hearts Connected.

Collateral Package - HCAN members only$150.00

1 Box of Business Cards, Letter head template, 100 Rack cards and 100 note cards

Digital Footprint Assessement$200.00

A large one-time assessment of your current digital footprint and one consulting call.

Consulting Services - Non members$125.00

Interested in consulting services to start or grow your business. $125/hour. HCAN members receive consulting services at $100/hour.

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Total $0.00

Refunds: Refunds will be issued if the application is not accepted. If the application is accepted, full refunds will be issued if a cancelation is requested by email (info@heartsconnected.org) PRIOR to onboarding. If there is a cancelation within 30 days of onboarding there will be a refund of 50% of initial fee.

Monthly fees will not begin until onboarding is complete.

Payment Methods

Debit or Credit Card

Choose from one of the PayPal options to make your payment.