Facility Intake Form
We are excited to connect your residents and community members connected with talented musicians across the U.S.A. to bring them joy through music during social isolation. Our live stream Zoom sessions are moderated by a Dottie team member (a staff member at your facility can also be a moderator). There will be no video, audio, or chat option for your residents in order to respect their privacy. Your residents can access the performance with a link on a web connected device or by calling in (rates may apply for individual carrier). A member of our team will  be in contact with you shortly after completing this form. Thank you!
Sign in to Google to save your progress. Learn more
Name of Facility/Community
Your name
Email
Phone number
How many residents/community members do you have?
Clear selection
What time would you like the performance? Select all that apply.
What date would you like the performance?
MM
/
DD
/
YYYY
Would you like more than one performance? If so please list dates below.
Would you like the name of your facility/community shared with the performer?
Clear selection
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy