MEMBERSHIP APPLICATION membership application for joining 9MusesArtCenter 9MUSES is a Membership Application program, requiring each member to complete & submit the following form prior to receiving services. Date* Date Format: MM slash DD slash YYYY Name:* First Last Address:* Street Address Apartment Number City: State: Zip: Email:* Phone number:*Emergency Contact* First Last Relationship:*Phone:*Demographics*Date of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Race or Ethnicity:*WhiteBlack or African-AmericanAmerican Indian or Alaskan NativeAsianNative Hawaiian or other Pacific islanderFrom multiple racesOthersGender:*FemaleMalePronoun:*he/himshe/herthey/theirOthersOur Product refers to users using the pronouns that you select below.Marital Status:*MarriedWidowedDivorcedSeparatedNever marriedIncome:*$0 – $18,000$18,000 & AboveEducation:*Less than high school degreeHigh school degree or equivalent (e.g., GED)Some college but no degreeAssociate degreeBachelor degreeGraduate degreeEmployment:*Employed, working 1-39 hours per weekEmployed, working 40 or more hours per weekNot employed, looking for workNot employed, NOT looking for workRetiredDisabled, not able to workCitizenship: USA*YesNoWho do you currently live with?*SpouseChildrenParentsFriendsAloneFamily BenefitsInsurance Information*MedicaidMedicareVeteransOtherNoneI Have received Mental Health services within the last 5 years:*YesNo(if no, annual membership fees apply)I am currently receiving behavioral health services at:*Community mental healthSubstance treatmentPrivate facilityNoneMy treatment providers name:Phone:My transportation provider name:Phone:My case manager’s name:Phone:I have received behavioral health services:*in the past 12 monthswithin the past 5 yearsAre you registered to VOTE in the State of Florida?*YesNoMHA'S CLIENT PROTOCOLS RECEIVED* By checking this box I affirm I have received and understood MHA's Client Protocols.CLICK HERE TO RECEIVE A COPY OF THE "MHA'S CLIENT PROTOCOLS" HAVE YOU RECEIVED THE 9MUSES MEMBERSHIP AGREEMENT THE 9MUSES MEMBERSHIP AGREEMENT* By checking this box I affirm I have received and understood The 9MUSES Membership Agreement.I HAVE SIGNED THE MEMBERS CONSENT/RELEASE FORM MEMBERS CONSENT/RELEASE FORM* By checking this box I affirm I have received and understood Members Consent/Release FormBy signing below, I authorize Mental Health America to release information regarding my participation for purposes of program development,data gathering and fund contract compliance.Consent* By signing below, I authorize Mental Health America to release information regarding my participation for purposes of program development,data gathering and fund contract compliance.MY INITIALS:*My signature affirms that this information provided by me is complete and accurate. Consent* My signature affirms that this information provided by me is complete and accurate.MY SIGNATURE:*Consent* I understand that my participation is voluntary and for the purpose of personal growth. I understand that it is not a treatment program and that it is my responsibility to select activities in which I can safely participate.I understand that my participation is voluntary and for the purpose of personal growth. I understand that it is not a treatment program and that it is my responsibility to select activities in which I can safely participate.MY SIGNATURE:*Upload Photo*PhoneThis field is for validation purposes and should be left unchanged.