Music Therapy Group Registration

Music Therapy Group Registration

For students with disabilities looking to connect with peers, develop social/communication skills, and have a fun space to express themselves in a creative way.
I am registering for...*
Check the box below if you are re-enrolling a current participant for the next session of this group.

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?*

YesNo
Emergency Contact Name*

First NameLast 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.

Medical Information