Imagine Through Music Group

Imagine Through Music Group

Registration Form
Group Details:

This group is for children in 1st - 2nd grades

Weekly Mondays 4:00 – 4:45

Sessions will be hosted via HIPPA compliant Zoom for heathcare account

Participants only need to have a free Zoom account

Each session is $100 for all 4 groups
Participant Information
Note: If multiple participants are enrolling in the group in the same family, please fill out a sperate registration form for each. Participants with disabilities are welcome!
Participant Name

First Name Last Name
Age
Address Participant will be at during groups (this will only be used in the event of an emergency)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Any relevant diagnosis, personality, or developmental information and/or special needs?
Parent/Guardian Information
I am this participant's

Parent Guardian
Name

First Name Last Name
Phone Number

Area Code Phone Number
Parent Email
example@example.com
How did you hear about our group?
Parent/Guardian Signature for consent to participate in group

Clear
Payment - Each 4 week session is $100

Payment is due by the first day of class.
Payment Method

Credit Card Check (Please contact melissa@livingspirittherapy.com to pay by check)

Please Check Which Session You Are Interested In

November 30th – December 21st: Imagine Through Music $ 100.00

January 11th - February 1st: Imagine Through Music $ 100.00

Total $ 0.00

If you have any questions or difficulty registering please contact melissa@livingspirittherapy.com
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Participant Information