The Price Legacy Fund Application

Please ensure you have enough time to complete and submit this application — with required documentation — in one sitting, as it does not “save as you go”.

The Price Legacy Application

Name*
First Middle Last
Address*
Street Address Address Line 2 City State ZIP Code
Date of Birth*
Gender Identity
Race
Email*
I would like to receive email updates from Music Health Alliance.
- Yes
- No
Phone*
Marital Status*
Number in Household*
How many family members do you claim on your tax return?
Music Business Affiliation*
What do you do and for how long have you been doing it?
Genre of Music*
What is your projected household income for the current year?*
Do you currently have health insurance?*
How can we help?
There is no wrong answer.
Are you a current Music Health Alliance client?
- Yes
- No
If you answer YES, please answer to the last question so we can better assist you. If you are NEW to MHA, please click submit and we will be back in touch shortly.
If you answered YES, who is your advocate?
Please select the advocate that you have worked with previously at Music Health Alliance.
How Did You Hear About Us?*
Required Verification Documents - Please Upload 2*
REQUIRED: Please select 2 of the following 4 document options to upload as proof of need: 1. Most Recent Tax Return 2. Most Recent Bank Statement 3. Employment or Unemployment Check Stub or Direct Deposit Documentation 4. Alternative Proof of Need Documentation or Letter of Explanation
Drop files here or

Max. file size: 100 MB, Max. files: 2.
Informed Understanding of Music Health Alliance's Purpose:*
I agree and understand the following:
I understand that Music Health Alliance is intended as a resource for healthcare advocacy, financial support, education and clinician referral purposes only. Music Health Alliance is not a substitute for psychotherapy, does not constitute medical advice, and is not a substitute for professional medical advice, diagnosis, or treatment. I will seek the advice of a physician, mental-health professional, or other qualified health provider with any questions regarding a medical or psychiatric condition.
Certification of Application*
I agree to the following:
I hereby certify that I have answered the foregoing questions to the best of my ability. The facts herein stated are true and I understand that any misrepresentation of this information may disqualify me for any assistance from the MHA Mental Health Fund.
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Phone
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The Price Legacy Fund Application

The Price Legacy Application

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