Music Therapy Registration Form
For individual and small group music therapy clients
Client's Name *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Parent/Guardian's Name (if under 18)
Your answer
Email *
Your answer
Street Address *
Your answer
Town/City *
Your answer
State *
Your answer
Zip Code *
Your answer
Phone # to be reached at on day of therapy session *
Your answer
Secondary Phone
Your answer
Please list any allergies (write N/A if none) *
Your answer
Will the client have an epi-pen in therapy sessions? *
Are there any other medical considerations you would like us to be aware of? *
Your answer
Primary Care Physician
Your answer
PCP's phone #
Your answer
Emergency Contact Name (in addition to the parent/guardian listed above) *
Your answer
Emergency Contact Relation *
Your answer
Emergency Contact Phone # *
Your answer
Permission to be photographed *
At times we may take pictures during group or individual sessions to share with the Sing Explore Create, LLC music therapy team. This is strictly for educational and supervision purposes. Pictures taken during music therapy sessions will not be used for promotional materials (unless a separate waiver is signed by the client) and will be kept confidential. Pictures and videos will not be shared with anyone outside of the music therapy team at Sing Explore Create, LLC (unless a separate waiver is signed by the client). Please check below to give permission or decline permission to photograph the client for the previously mentioned reasons.
Permission to be recorded *
At times we may take pictures during group or individual sessions to share with the Sing Explore Create, LLC music therapy team. This is strictly for educational and supervision purposes. Pictures taken during music therapy sessions will not be used for promotional materials (unless a separate waiver is signed by the client) and will be kept confidential. Pictures and videos will not be shared with anyone outside of the music therapy team at Sing Explore Create, LLC (unless a separate waiver is signed by the client). Please check below to give permission or decline permission to photograph the client for the previously mentioned reasons.
Medical Attention *
In the event of an emergency requiring medical attention, I understand that Sing Explore Create, LLC will make every effort to contact and notify the listed parent/guardian and emergency contact listed above. However, if neither can be reached Sing Explore Create, LLC reserves the right to call emergency personnel to transport the student to the nearest medical facility to secure necessary medical treatment.
Pick Up Policy
For students under age 18, we reserve the right to ask for picture identification from anyone picking up clients from Sing Explore Create, LLC studios. Only those who have been given written permission from the clients' parent/guardian will be allowed to pick up. PLEASE LIST THE NAMES OF THOSE WHO MAY BE PICKING UP THE CLIENT BELOW. In the event that a client music be picked up from lessons by someone not listed below, hand-written notification and permission from the parent/guardian must be given to the music therapist prior to the client being dismissed.
Your answer
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