JWF Initial Request Form

JWF Initial Request Form

Musician Health & Services Program
I have reviewed the JWF Musician Health & Services Program page at www.thejwf.org/map before completing this request form*

YES
Today's Date*

MonthDayYear
Applicant's Name*

First NameMiddle NameLast Name
Preferred Pronoun

She, Her, HersHe, Him, HisThey, Them, TheirsOther
Applicant's Professional Name a/k/a (if different from above)

First NameMiddle NameLast Name
My primary residence is in Oregon or Clark County, Washington.*

YESNO
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Mailing Address (If different from Home Address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*
Please provide detailed and accurate information in response to the following questions:
Are you currently experiencing a serious medical or mental health condition that interferes with your ability to work within or outside the music industry?*

YESNO
Your Official website or website featuring your work or affiliation URL*
example: https://www.thejwf.org/
Your Facebook or main social media website URL*
example: https://www.facebook.com/theJWF
How many years have you worked in the music industry?*
In what capacity? (choose all that apply)*

Performing musicianMusic industry worker
Please provide a brief description of what you do as musician or music industry worker:*
If yes to the above question, please list the date and venue of your last six (6) shows.*
If you do not perform regularly or if you have not been performing as much as usual, please explain in the above box.
Do you consider yourself a professional or semi-professional musician (performer, recording artist, composer, arranger, DJ), or professional or semi-professional music industry worker who provides services for bands, shows, or tours (e.g., crew, sound, lighting, production, etc.)?*

YesNo
If yes to the above question, please list the date, venue, city, and state of your last six (6) shows, projects, clientele or industry-related jobs. List gig #1 here:*
Example: 04/23/2024 "gig name" The Alberta Rose Theatre, Portland, OR.
List gig #2 here:*
Example: 04/23/2024 The Alberta Rose Theatre, Portland, OR.
List gig #3 here:*
List gig #4 here:*
List gig #5 here:*
List gig #6 here:*
In addition, please list any published recordings to which you have contributed in the past five (5) years.*
If you have not contributed to any recordings, please explain in this box.
Do you consider yourself a professional or semi-professional music industry worker who provides services for bands, shows, or tours (e.g., crew, sound, lighting, production, etc.)?

YesNo
If yes, please list your recent clientele and provide a list of up to 5 examples of any work you have helped to produce or tours you have worked in the past 10 years.
If NO? Please write N/A in the above box.
On average, how many hours per week do you dedicate to your work as a musician or music industry worker?*

less than 55-1010-2020+
On average, what percentage of your monthly income comes from your work as a musician or music industry professional?*

0-25%26-50%51-75%76-100%
Are you currently employed outside of the music industry?*

YESNO
If you have any additional information to share about your music career that could support your eligibility for assistance from the JWF, please do so in the box below.
Request for Assistance

Please help us understand the help you are requesting from the Jeremy Wilson Foundation.
Choose one:*

I am experiencing financial hardship due to a serious medical or mental health condition that interferes with my ability to work within or outside the music industryI am NOT experiencing a serious health condition and related financial hardship. I need help with OHP/Medicaid, Marketplace or other insurance, or help accessing health care.
Choose one:*

I am experiencing financial hardship due to a serious medical or mental health condition that interferes with my ability to work within or outside the music industryI am NOT experiencing a serious health condition and related financial hardship. I need help with OHP/Medicaid, Marketplace or other insurance, or help accessing health care.
Please provide a brief description of your request for assistance:*
Important

We need to verify the contact info of the person filling out this form. Please fill in all required information below even if you have already done so in the previous section.
Who is filling out this form?*

I am the person in need of assistanceI am applying on behalf of the person in need of assistance
Name of person filling out this form*

First NameLast Name
Relationship to applicant?*
E-mail of person filling out this form*
CONFIRMATION OF SUBMISSION WILL BE SENT TO THIS EMAIL ADDRESS
Phone Number of person filling out this form*

Area CodePhone Number
How did you learn about The Jeremy Wilson Foundation?*

Google/internet researchAn event or show that benefitted JWFAnother similar assistance program, such as Musicares or Sweet Relief211Another musician or music industry workerOther
If you are able, please tell us a bit more about how you heard about the JWF and what motivated you to seek assistance from our organization. This information helps us improve our outreach to the music community.
Statement of Non-Discrimination

The Jeremy Wilson Foundation does not and shall not discriminate on the basis of race, color, religion, ethnicity, gender, gender expression, age, national origin or ancestry, disability, marital status, sexual orientation, or military status when evaluating applications for funding.
I hereby certify that I have answered the foregoing questions to the best of my ability. The facts as stated are true and I understand that any misrepresentation of this information may disqualify me for any assistance from The Jeremy Wilson Foundation. I further acknowledge that any information provided herein is being offered voluntarily and for the explicit purpose of requesting assistance from The Jeremy Wilson Foundation.*

I agree
Should be Empty:

JWF Initial Request Form

Request for Assistance

Important

Statement of Non-Discrimination