MusiCares Disaster Relief Grant Request Form

How did you hear about MusiCares

What is the name of the referring organization?

Please review before continuing:  

You must show proof of at least 5 or more years of paid professional experience in the music industry   AND/OR at least 6 commercially released singles and/or music videos 
MusiCares may provide financial assistance to eligible music industry professionals who are in geographic areas impacted by natural disasters.
Completing the following questions does not guarantee assistance. MusiCares will contact you shortly after receiving your completed form. Please note this process can take at least five business days.

If you cannot complete the online form due to lack of internet access,

please call us at 800.687.4227 

Non-Discrimination:

MusiCares does not discriminate on the basis of race (nor traits historically associated with race), color, religion, creed, sex, national origin, ancestry, age, physical disability, mental disability, medical condition, family care status, military or veteran status, marital status, sexual orientation, gender, gender identity, gender expression, genetic information or any other characteristic protected by law. If an individual opts to disclose demographic information, MusiCares may use that information for the purpose of ensuring our programs are inclusive and representative in their reach.

Privacy & Confidentiality

MusiCares maintains the privacy and confidentiality of all clients’ medical records and personal information in compliance with local, state and federal laws and regulations, including, but not limited to the Health Insurance Portability and Accountability Act (including the federal regulations implementing such law), as amended by the Health Information Technology for Economic and Clinical Health Act, and as it may subsequently be amended. MusiCares will not use or disclose clients’ medical records to any other third party, except as required by law. MusiCares takes all reasonable measures to protect the clients’ medical records from theft, loss, unauthorized destruction and unauthorized access.

spambot catch field

General Information

First Name

Last Name

Professional Name (or band name, if different)

Spouse/Partner Name (if applicable):

Home Address or Mailing Address Line 1:

Address Line 2:

City:

State

Zip/Postal Code

Primary phone number

Date of Birth

Do you have dependents?

YesNo

How many?

Ages of Dependents:

Please list anyone you give MusiCares permission to contact regarding your grant request.

Name, Email, Phone, Relationship

Professional History

How long have you worked in the music industry?

In what capacity?

Professional Documentation

Please share your primary social media link documenting your professional music career:  (Instagram, Facebook, professional website, etc.)  Note NA if this is not applicable to you

Please list links where your music can be purchased - All Music, Jaxsta, Apple Music, Amazon Music, Spotify, etc. Note NA if this is not applicable to you

If you do not have links, upload proof of music industry work which include, but not limited to biography, resume, PROS statements, electronic press kit, discography, liner notes, promotional materials, paystubs, W2s showing music work

Page 4

Briefly describe how you were impacted by the disaster

If you lost gigs/work due to cancelations, please provide information about venues and dates.

Upload any additional information that can help us to better understand how the disaster impacted you/your family.

Thank you for contacting MusiCares. We will review your request and be in contact within five (5) business days.

Confirm  the mailing address noted on the form is correct. If assistance is provided, we will use this mailing address as your primary contact.
.

HIPAA

I understand that my Health Information that is disclosed pursuant to this Authorization may be re-disclosed by the recipient of that information and may no longer be protected by the Health Insurance Portability and Accountability Act (HIPAA) or other applicable privacy or health privacy laws. Except as expressly stated in this Authorization, nothing in these acknowledgements or this Authorization shall be considered as a waiver of any rights to privacy or nondisclosure of information that I may otherwise have under any applicable law.

I agree

ASSISTANCE LIMITATIONS

When financial assistance is provided by MusiCares, it is charitable in nature and therefore, before seeking such assistance, applicants are required to investigate all other possible sources of aid. All approved assistance is paid directly to a creditor or third party on behalf of the grant recipient. At its sole discretion, MusiCares reserves the right to deny, rescind or approve financial assistance at any time. MusiCares shall deny, revoke, rescind, or terminate grants at any time when MusiCares has reason to believe that an applicant or grant recipient has engaged in negligence, misrepresentation, falsification, nondisclosure, recklessness, or abuse of aid. Upon discovery of such negligence, misrepresentation, falsification, nondisclosure, recklessness or abuse of aid, if MusiCares has already distributed grant monies on behalf of the grant recipient, such grant recipient shall immediately reimburse MusiCares in full for any such grant monies.

I agree

human test field what is 2+2

Contact Information