Tones of Fun Developmental Music Class - Concord Conservatory
Please complete this form to apply for the Tones of Fun Developmental Music Class Program at the Concord Conservatory of Music. Applications will be reviewed by our team and will contact you directly to arrange a follow-up meeting and/or phone call.

For questions or more information, please contact Dr. Rhoda Bernard by email at rbernard@berklee.edu or by phone at 617-747-2760.

Thank you for your interest in our program; we look forward to meeting you soon.
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Email *
Student's Legal First Name *
Student's Legal Last Name *
Student's Age (as of September 1) *
Student's Sex at Birth *
Name of the School the Student Attends (as of September 1) *
Grade Level (as of September 1) *
Country of Citizenship *
Country at Birth *
Please check one or more of the following groups in which you consider yourself to be a member: *
Primary Language *
Student's Specific Diagnosis *
All students in the Tones of Fun Developmental Music Class must have a diagnosed disability. Students who do not have a diagnosed disability cannot participate in this program.
Family Information
Parent or Guardian's Name *
Parent or Guardian's Email Address *
Parent or Guardian's Relationship to the Student *
Parent or Guardian's Phone Number(s) *
Parent or Guardian's Address Line 1 *
Parent or Guardian's Address Line 2 *
City *
State/Province *
Postal Code *
Country *
Participation is dependent on acceptance to the program and availability.
Program Information
How does the student communicate? *
At what level does the student communicate? *
How does the student express their feelings? *
Please describe the student's school program, if applicable.
What does the student like to do during spare time? *
What motivates the student? *
What does the student dislike doing? *
What is your vision for the student? *
Please provide any other information that will help us to better understand the student and their musical needs. *
Please provide any information that will help us to better understand the student and their learning needs. *
Please describe in detail any behavioral issues that the student may have that might impact the lesson, and provide information about ways to manage those issues effectively. *
Please describe in detail any attention issues that the student may have that might impact the lesson, and provide information about ways to manage those issues effectively. *
Please describe in detail any sensory issues that the student may have that might impact the lesson, and provide information about ways to manage those issues effectively. *
Emergency Contact Information: Contact 1
 Provide contact information for an individual in case of an emergency.
First Name *
Last Name *
This emergency contact is a parent/guardian. *
Email Address *
Mobile Phone Number *
Address Line 1 *
Address Line 2
City *
Postal Code *
Country *
 Emergency Contact Information: Contact 2
 Provide contact information for an individual in case of an emergency.
First Name *
Last Name *
This emergency contact is a parent/guardian. *
Email Address *
Mobile Phone Number *
Address Line 1 *
Address Line 2
City *
Postal Code *
Country *
Healthcare Provider Information
Family Doctor *
Family Doctor's Phone Number *
Family Dentist *
Family Dentist's Phone Number *
 Medical Insurance
Group Number
Company Name
Medical Insurance ID Number
Medical Insurance Member Name
Medical History
Allergies, If Any, Including Medications and Foods
Chronic or Existing Diseases or Medical Problems (i.e., diabetes, epilepsy)
Medications Student Is Now Taking, and Dosages
Date of Last Tetanus Injection or Booster (if known)
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DD
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YYYY
Please Note
Our staff cannot administer any medications, prescription or nonprescription, to program attendees. The program nurse may administer nonprescription medications, such as Advil or Tylenol, only after speaking with a parent or guardian. If the attendee will need to take prescription medications while attending the program, they must assume responsibility for taking the medication as needed or indicated. Please indicate your permission for your child to self-administer the medication(s) listed above by signing this form.
By signing, I certify that the above-named student is physically fit to participate in the Tones of Fun Developmental Music Class. The health information provided on this form is correct to the best of my knowledge.
Parent or guardian: type your name to sign the Emergency Contact, Health Care Provider, and Medical History sections of this form. *
Date *
MM
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YYYY
A copy of your responses will be emailed to the address you provided.
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