Musical Map for Dementia Application Form
Thank you so much for letting the us know about your musical event and/or services for people living with dementia and their carers.
Once you have submitted the form, we will assign you a Username and Password, which will allow you to edit and check your details and insert further information about your musical offering into our database.
As you can imagine, the Musical Map for Dementia has proven very popular so please do allow us some time to get back to you.
By working together we are making music accessible for people living with dementia across the UK. Thank you for agreeing to include your information in the Musical Map for Dementia and your continued support for the M4D2020 Campaign.
Music for Dementia 2020 Team
Please note by agreeing to complete this form you agree to the Terms & Conditions on our website
Address (please include the postcode)
Please provide your website and/or social media link
Please select you musical event/service type
Individual Music Therapist
Music Therapy Service/Centre
Interactive/Participatory Music Making - Individual
Interactive/Participatory Music Making - Group
Intergenerational music group
Live music performance - Individual
Live music performance - Group
What is the Name of the event/service?
Please provide a brief description of your musical offering
Size of group
Cost per session
What is the name of the event/service leader?
What is the event leader's email address?
What is the event/service leader's contact number?
Would you like to include any qualifications for the event/service leader?
Please add the event location address or the area your service covers
Venue Amenities (Please select)
Hearing Loop System
Our event/service is suitable for (please select a dementia phase as appropriate)*
Post diagnosis - early years
Post diagnosis - later years
End of life
Benefits (Please select as appropriate)*
Contributing to a creative outcome
Creative expression and stimulation
Enhancing spiritual activity
Improves cognitive skills
Maintenance or development of identity and self
Pleasure and enjoyment
Social connections – supporting relationships
Yes a referral is required
Please add further information is a referral is required
Is there any further information you need to tell the M4D2020 Team about your event / service?
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