Contact Us - Employer Enrollment Form

Employer Information

Company Name:*

Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Number of Employees Employed at the Company*

Main Contact

Main Contact Name*

First Last

Phone*

Email*

HR Contact

HR Contact Name

First Last

Phone

Email

Billing Contact

Billing Contact Name

First Last

Phone

Email

Insurance Carrier

An information welcome packet will be sent to you to share with your team and employees

Employer understands that enrollment in the Hope Works program is meant to minimize the economic impact of child loss grief or medically complex diagnosis of a child in the workplace. Faith’s Lodge offers no guarantees related to economic savings or job performance. Faith’s Lodge makes no guarantees regarding benefits obtained by employee or employer from the program and the elements therein. Enrollment allows the employer to offer the program as a benefit to their employees. Faith’s Lodge, the assigned transition coach or any of their affiliates are not liable for any damages or losses related any employee’s grief or services provided. Employer releases Faith’s Lodge from all liability related to the program.

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