Community Class Registration
Be sure to register for Mosaic Therapy Collectives Inclusive music series, Lanny's Music Fun! See you there : ) 
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Parent/ Guardian Name: *
Child/ Children's Name(s) *
Child/ Children's Ages)
Phone Number
Email *
Does your child have a disability &/or any additional support needs we should know about? *
(For grant-funding data collection purposes) Please identify:
Household income
less than $35,500
$35,000 - $47,900
$48,00 - $79,000
$94,800 - $128,000
$120,000+
For grant-funding data collection purposes, please identify: 
2
3
4
5+
Family size
Given the cost of living in Santa Barbara County, would you consider yourself: 
Clear selection
I identify my ethnicity as:
Does your child have a diagnosis of: 
Clear selection
How did you hear about us? 
Thank you for registering for the event! We look forward to seeing you there : ) Anything else you would like to share with us?
Submit
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