MEMBERSHIP APPLICATION

Membership Application for Joining 9musesartcenter

"*" indicates required fields

9MUSES is a Membership Application program, requiring each member to complete & submit the following form prior to receiving services.
MM slash DD slash YYYY
Name*
Address*
Emergency Contact*
Demographics
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Gender:*
Our Product refers to users using the pronouns that you select below.
Citizenship: USA*
I Have received Mental Health services within the last 5 years:*
(if no, annual membership fees apply)
I have received behavioral health services:*
Are you registered to VOTE in the State of Florida?*
MHA'S CLIENT PROTOCOLS RECEIVED*
My signature affirms that this information provided by me is complete and accurate.
Consent
Consent
Max. file size: 100 MB.
This field is for validation purposes and should be left unchanged.