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Richard M. Bates SMILE 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”.

Richard M. Bates SMILE Fund Application

The purpose of the Richard M. Bates SMILE Fund to provide critical dental healthcare for music industry professionals with limited financial means.

Grant Qualification Requirements:*
Yes, I meet the below grant qualification requirements.
To qualify for The MHA Mental Health Fund, applicants MUST have:
1. Made a living by working in the music industry for 3+ years. This must be verifiable by MHA Staff.
2. Have a projected annual household adjusted gross income at or below 300% of the Federal Poverty Level. See link on previous page if you are unsure.
3. Have an emergent dental need (no wisdom teeth removal or routine cleanings qualify).
4. Have a dental treatment plan that can be uploaded for review.
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 or dental insurance?*
What is your dental need? It is important that you have seen a dentist to know what your emergent need is and the projected cost.*
There is no wrong answer.
Please upload your dental treatment plan here.*
Drop files here or

Max. file size: 100 MB.
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.
Required Verification Documents - Please Upload 2*
REQUIRED: We need your most recent tax return and at least one other of the following 2 document options to upload as proof of income need: 1.. Most Recent Bank Statement 2. Employment or Unemployment Check Stub or Direct Deposit Documentation
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 does not constitute medical recommendations, and is not a substitute for professional medical advice, diagnosis, or treatment. I will seek the advice of a physician, dentist, or other qualified health provider with any questions regarding my dental and/or medical 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 Richard M. Bates SMILE Fund at Music Health Alliance.
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Phone
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Richard M. Bates SMILE Fund Application

Richard M. Bates SMILE Fund Application

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