Student First Name *
Student Last Name *
Date of Birth (mm/dd/yyyy) *
Guardian First Name (enter “Self” if student/client is adult without guardian) *
Guardian Last Name (enter “Self” if student/client is adult without guardian) *
Guardian or Adult Student Phone *
Guardian or Adult Student Email *
Student Phone *Optional
Student Email *Optional
Preferred Music Therapist *
Preferred Session Day and Time *
If that’s not available, what other days/times would work? *
Please provide any additional info that will help with scheduling.
In consideration of participation in this program, I hereby release and discharge the Manchester Community Music School and its representatives, employees, officers, directors, successors, and assigns, from any and all liability arising from accident, injury, and illness that may be encountered as a result of participation in this program. *
MT Missed Session Policy: · In case of illness or absence, your Music Therapist (or MCMS representative) will contact you to cancel the session. MCMS weather-related closings are listed on WMUR and a representative from MCMS will also contact you. If you are unsure about closing or delays, please contact MCMS at 603-644-4548 (initial here) · We will offer a make-up for any session missed by MCMS (due to illness, weather, or other closures). These make-ups will be scheduled with your music therapist, either in-person or virtually (initial here) · In case of client illness or other absences, one make-up session per year is available, if the cancellation is made with 24-hours notice. If a session is cancelled with less than 24-hours notice, a make-up session is not required and will be determined on a case-by-case basis. (initial here) · If you have any questions about this policy, please talk with your Music Therapist or the Director of Music Therapy. By signing below you agree that you have read and understand this policy. *
Guardian Signature *
Manchester Community Music School
info@mcmusicschool.org
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