LA Fire Disaster Relief Application

LA Fire Disaster Relief Application
Sponsored by the Los Angeles Branch

for SMAC TEACHERS and their STUDENTS
Teachers are welcome to submit an application on behalf of any of their students.
Your Name*
Must be a current SMAC member
Email Address*
Mobile Phone*
XXX-XXX-XXXX
Street Address of Fire-Affected Home*
City*
Zip Code*
This aid application is for:*
Name of Person(s) you are requesting assistance for
Please describe the loss or damage to your instrument or equipment (complete loss, partial loss, beyond repair, salvageable, etc)
Type of instrument or equipment affected.*
piano, violin, cello, microphone, computer, etc.
Instrument maker or equipment manufacturer*
Steinway, Jay Haide, Apple, etc.
Size of instrument affected*
Describe what, if any, insurance coverage for this instrument or equipment exits*
Not insured, insured up to a certain $ amount, partial coverage, etc.
What help are you looking for?*

Instrument rentalInstrument repairFunding for replacementInterim loanStudio rental spaceOther
Anything else you would like us to know?
Amount or type of aid requested*
What for?

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