Approved Provider Setup Form

Approved Provider Setup Form
We’re so grateful for your interest in partnering with Good Soil. This short form helps us get you set up as an approved provider so we can begin supporting the families you serve.
Organization Information
Organization Name*
Primary Contact Name*
Primary Contact Email*
Primary Contact Phone Number
Format: (000) 000-0000.
Website
Services
Type of Organization*
Please specify*
If you selected Other, please provide more details.
Grade Levels*
In-personOnlineBoth
Payment Information
ACHCheck
Mailing Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Uploads
W9*

Cancelof
Pricing Sheet / Service Information

Cancelof
Visibility & Listing
YesNot at this time
Agreement
Please review and confirm the following:
- Scholarship funds are distributed directly to approved providers based on student awards and available funding
- Submission of invoices does not guarantee payment and is subject to student eligibility and available funding
- I will provide accurate invoices and only bill for services that have been completed
- I will communicate any changes to services, pricing, or student participation
- I understand that provider approval may be reviewed and updated as needed
I agree to the terms above
Should be Empty:

Organization Information