Her PLAN Directory Form

We look forward to featuring your organization in our directory of life-affirming assistance providers. Please provide the information below so we can move forward with your listing. Our team will review your information and be in touch if further information is needed before publication. Please don’t hesitate to contact us if you have any questions.

Contact Info

First name*

Middle Name

Last name*

Your email for Her PLAN communications*

Org email to display on directory (This can be same or different than above email.)*

Company or Organization Name*

Website URL

Street address

Your phone number for Her PLAN communications

Phone number to display on directory (This can be same or different than above.)*

Services

How would your services benefit a pregnant/parenting woman or family with children under age 2 (whether or not they are your only demographic)?*

Please select the options below that most closely align with the price(s) you charge: *

Other price details

Insurance

We ask providers if they are insured for compliance purposes in vetting groups prior to listing. This allows us to provide a top-quality directory so you can refer to other organizations listed with confidence. Let us know if you would like more information.

For organizations with a physical location, mobile unit location, or office, we look for general liability insurance (sometimes called slip and fall insurance or business owners insurance). Does this apply to you?*

Yes – we have general liability insurance.

N/A – clients come to my home and are covered by my homeowners insurance.

N/A – our services are only virtual and/or we meet at neutral locations such as coffee shops, others' homes, or churches that share their space.

No – we have chosen not to carry general liability insurance.

Other

For organizations or individuals providing certain professional services, we look for professional liability insurance (an example of this is malpractice insurance). Do you have professional liability insurance?*

Yes – we have professional liability insurance.

N/A - professional liability does not apply to our services

No – we have chosen not to carry professional liability insurance.

Other

Permissions

“We”, “Our” refers to the organization/company listed under “Contact Information” in this form.

We are a life-affirming organization. We do not support abortion. Our staff and volunteers do not refer for abortion while providing our services. *

We authorize Her PLAN to feature us in their public directory and grant permission for Her PLAN to use our name/contact information/logo in their web and print directories and other marketing materials and communications such as newsletters.**

We will not hold the Susan B. Anthony List Education Fund, Inc. or Her PLAN liable for any losses or damages as a result of our participation in Her PLAN and/or my being listed as a provider in Her PLAN.*

We certify that we serve clients/patients without regard to age, race, income, nationality, religious affiliation, disability or other arbitrary circumstances or we limit services to particular populations for bona fide reasons such as providing gender-specific housing (e.g. domestic violence shelters for women only), or serving a specific minority or at-risk population (e.g. Latino legal service).*