Participant's Age

Parent's Name

Parent's Email

Phone Number

Address

Tell Us About You!

Tell us a little about the participant's interests and things that you like to do, as well as any adaptations or modifications that might be needed.

Your Favorite Music

Please list a few favorite music artists/genres of music so we can tailor the class to your favorites!

Liability Release

I fully understand the potential risk of injury common to participating in music therapy groups as well as potential risk in participating in online classes and fully assume the risks associated with such participation. I hereby release, and on behalf of my child I hereby release, Keys for Success, LLC and it’s officers, directors, employees, instructors and independent contractors from and against any and all claims, demands, actions of whatsoever kind or nature, causes of actions, damages, costs, liabilities, expenses or judgments, including, but not limited to, attorneys’ fees and court costs and any other liability for any and all injury, loss, damage, misadventure and/or inconvenience occurring to my child or arising out of my child’s participation in the programs. (please type signature below)

Acknowledgement of Receipt of Privacy Notice

I acknowledge that I have had the opportunity to review an executed copy of this acknowledgement and a copy of Keys for Success’ HIPAA Policy Notice (available in print upon request or at www.keysmusictherapy.com/forms) and agree to Keys for Success’ Use and Disclosure of my protected PHI for treatment, payment and health care options.

Virtual Camp Acknowledgement

I understand that this camp will take place virtually via an online video platform. I understand that Keys for Success will take all precautions for online privacy and confidentiality. I understand that I am fully responsible for providing the needed technology for participation in this camp and acknowledge that I will provide someone to help my son or daughter during the camp time should we have a technology challenge. (please type signature below)