Online Affiliation

You may use this form to quickly renew your affiliation, please select the appropriate rate using the definitions below.

  • Complimentary- This rate is for start-up centers in their first year. All others will be subject to cancellation.
  • Discounted Affiliation- This rate is for centers who are affiliated with another National Affiliation Organization (NIFLA, CareNet, ICU Mobile, Save the Storks, Life Matters Worldwide, International Life Services,, Christian Life Resources, National Christian Adoption Fellowship, National Life Center)
  • Affiliation- Select this rate if you are not affiliated with another National Affiliation Organization and have been in existence for more than a year.

Please be sure to review and update the organization's information through your Contact Dashboard.

Become an Affiliate

Thank you for your interest in affiliation with Heartbeat International. Please make sure you have reviewed the information about what it means to be a Heartbeat Affiliate, as well as the Committment of Care and Competence before completing your affiliation. Once you complete the online application, we will review your request for affiliation. You will be receive a follow-up email when your affiliation has been approved.

 
Total Amount
Affiliation Renewal

General Organization Information

Please provide the address you receive mail at:
United States
Please provide the physical address. If it is the same as your mailing address, please enter it a second time.
United States

Annual Statistics

If you are a new organization and have not collected this information yet, please indicate "0" or "NA" where appropriate.

This number should reflect the total of unique, individual clients served.
This number should account for multiple visits from the same client.
  

Services Information

Please provide information about the services offered through this location. Services and hours for satellite locations can be added at a later step.

Please select an "Open" and "Close" time for each day of the week. If closed that day, please select "closed" from the list. If there are exceptions to these times, please indicate these using the "Service Hours Notes" field below.

Please use this space to indicate any availability outside of these hours (i.e. 24 hour hotline), and/or any exceptions to this availability (i.e. closed for lunch 12-1).

Please indicate what language(s) are spoken by staff in your organization and are available for clients to receive counseling and/or services in.
 

Affiliation Agreement

Affiliates of Heartbeat International agree to uphold The Commitment of Care and Competence and Heartbeat Principles. Please click here to review Heartbeat Principles and The Commitment of Care and Competence if needed.

The undersigned certifies that he/she is qualified to sign on behalf of the corporation.
Please indicate today's date.
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Billing Name and Address
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United States
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