Fill in this form to apply

The Musicians’ Hearing Health Scheme is a service from the UK charity Help Musicians, delivered in partnership with Musicians’ Hearing Services.

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* 1. Please tell us a bit about yourself

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* 2. Your Date of Birth
(Please select the correct year)

Date

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* 3. Are you a Musicians' Union Member?

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* 4. Do you have a PRS and/or a PPL number?

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* 5. Please tell us in which nation/region you live

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* 6. Which clinic location would you prefer to come to?

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* 7. Do you predominantly earn your income from music?

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* 8. Are you currently studying music at undergraduate level or above? If so please tell us what you are studying and where.  If you are not please just write no.

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* 9. If you are an instrumentalist please select your principal instrument

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* 10. How long have you worked in music?

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* 11. Please select the option that occupation which most closely matches your role in music

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* 12. Please select the genre which best describes your work

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* 13. Please give us 4 links to evidence of your work and/or your career.

We would like to see examples such as links to your website, soundcloud, youtube, social media, reviews of your work, and/or a digital CV such as linkedin. Each link must be to a separate website. The links must include www. when you enter them into the boxes below (ie. www.mymusic.com - not mymusic.com)

Please note that if we are unable to make an assessment based on the examples you provide we will contact your referee, and the assessment period will be extended to a calendar month. If you don't have any links to your work then please simply fill the boxes with 'n/a' and we will contact your referee.

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* 14. How did you find out about the Musicians Hearing Health Scheme?

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* 15. Please give us the contact details of someone who knows your work and would be happy to act as a referee for you.

This person should be someone who knows you and your work professionally - not a family member.

If the links you provide in response to Q9 are not adequate for us to make an assessment of your eligibility we will contact your referee, and the assessment period will be extended to a calendar month.

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* 16. Have you previously had any contact with Help Musicians (previously known as the Musicians Benevolent Fund)? This could have been with any of our Health & Welfare, Creative, Fundraising or Communications teams.

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* 17. Would you be happy for Help Musicians to contact you about your experience of the Musicians Hearing Health Scheme?

We would like to know a little more about you so we can measure the impact of the work we do.  The information you provide in the next few questions will not be used as part of your assessment and will not be passed onto anyone else.

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* 18. Please select the option that best describes your ethnic origin

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* 19. How would you describe your gender?

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* 20. Do you consider yourself to have a disability?

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* 21. Sign me up to receive emails with the latest news, events, funding opportunities and appeals from Help Musicians. I agree to the Privacy Policy.

You can opt-out at any time. For further information about how we process your data, please visit helpmusicians.org.uk/privacy-policy.

To submit your application, please press SUBMIT below.

Once you have submitted your application, Musicians' Hearing Services will be in touch within 10 working days.

Data Protection Statement:

Any information submitted, including any personal information you submit, will be used by Help Musicians and Musicians' Hearing Services staff to provide successful applicants with access to the scheme's benefits. Application data will be added to Help Musicians and Musicians’ Hearing Services internal databases if the application is successful.

Please note that all data provided to Help Musicians and Musicians' Hearing Services via Survey Monkey is transferred to and stored outside of the countries or jurisdictions of the European Economic Area on a secure server in the USA. In compliance with the Data Protection Act, Survey Monkey complies with the EU-US Privacy Shield Program and will take all steps, reasonably necessary to prevent the loss, misuse or alteration of personal information. Under the terms of their Privacy Policy, they endeavour not to, under any circumstances, contact survey takers or share their data with any other party, except in response to a complaint or under a duty to disclose or share your personal data in order to comply with any legal obligations.

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