MT & CAW for Adults Registration

Music Therapy and Creative Arts Wellness for Adults with Disabilities
I am registering for... *
Please check the box below if you are re-enrolling a current participant for the next session of this class.

I am re-enrolling a current participant.

Medical Information

We collect medical information for all in-person and virtual services. The information provided would be used should we need to contact emergency services during your time with us.
Please list any allergies. Write "N/A" if none. *
Do you have an epi-pen? *

Yes No
Emergency Contact Name *

First Name Last Name
Emergency Contact Relation to Student *
Emergency Contact Phone *
Please enter a valid phone number.
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/client to the nearest medical facility to secure necessary medical treatment. This applies to sessions at our center, at-home visits, and online sessions.
*

I have read and agree to the above statement regarding medical attention.

Music Therapy and Creative Arts Wellness for Adults with Disabilities