Service Provider Enrollment Form

Love You Well Program - Provider Enrollment

Please provide all required details to register your service or business with us.
Service/Product Provider*

First NameLast Name
Name Of Business You Work At*
Check box if owner

Yes, I am the owner
Check service(s) you can provide

Mani/Pedi In Recipient's HomeMani/Pedi At SalonHair Services In Recipient's HomeHair Services At SalonEsthetician Services In Recipient's HomeEsthetician Services At Salon/SpaMassage Therapy In Recipient's HomeMassage Therapy At SpaLash Extensions In Recipient's HomeLash Extensions At Salon/SpaHair/Wig RetailerNeuropathy TreatmentAcupuncture TreatmentProducts for Self-Care KitsPermanent MakeupChiropractic ServicesOther
Contact Number*
E-mail*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Type of Business*
Please select preferred form of payment and provide payment details below *
Check By Mail- Mail to address (if same as above type same, otherwise provide address).
Venmo Account Name
*This information will remain private and only used to remit payment after products or services are completed.
PayPal Account Name
*This information will remain private and only used to remit payment after products or services are completed.
Cash App Account Name
*This information will remain private and only used to remit payment after products or services are completed.
Message
When submitting this form, you agree that Love You Well Foundation may use your information to publish your business details in our provider list on the Love You Well Foundation website and social media platforms. You may withdraw your enrollment in the Love You Well Program anytime by emailing loveyouwell@solga.org or texting (580)560-4712.
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Love You Well Program - Provider Enrollment