🎵 Music With Jenn Registration Form Music Therapy • Adapted Music Lessons • Creative Arts Wellness
Music with Jenn – Jennifer Loucks, MT-BC (#11278)

4515 Culver Road, Suite 201

585-709-5840

Musicwithjenn@gmail.com

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🎓 Student Information
Name: *
Date of birth: *
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Age of child: *
School Attending: *
Student email (if applicable)
📍 Address
Street Address: *
City *
State *
Zip *
Primary Phone: *
Parent/Guardian Email: *
👨‍👩‍👧‍👦 Parent/Guardian Information
Parent/Guardian #1 Name: *
Phone  *
Parent/Guardian #2 Name: *
Phone  *
Emergency Contact Name: *
Relationship to student: *
Emergency contact phone: *
⚕️ Health & Support Needs
Please list any diagnoses, allergies, sensory needs, mobility needs, or important behavioral information to support the student’s experience: *
🎶 Class or Service You’re Registering For
(✓ Check all that apply) *
Required
If selected box for Adapted or General Music Lessons, check each instrument that applies: *
Required
💳 Payment Preferences
(✓ Check one) *
Required
Start Date  *
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End Date (If known)
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✍️ Signatures
Parent Signature: *
Date: *
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Student Signature (If applicable):
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📢 Additional Info

Any other information you’d like us to know?

Permission to post photos/videos on social media (Instagram: @MusicWithJenn):

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