Music Therapy Participation Waiver and Consent

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Please complete this form to participate in the "Reclaiming Music" program in collaboration with Berklee Health and Wellness and the Center for Music Therapy at Berklee college of Music.

These services may consist of assessment, group wellness sessions, and evaluations to monitor program success.

Information will be reviewed for by our board certified music therapist and details regarding start dates, times, and location will be provided to you via email for group start dates/times.

For questions or more information, please contact the Center for Music Therapy at: centermt@berklee.edu

Email *

Participant's First Name *

Participant's Last Name *

Date of Birth *

YYYY

Participant's Age *

Major

Semester Level *

Primary Language *

Please check one or more of the following groups in which you consider yourself to be a member: *

Asian

Black or African American

Hispanic/Latino

Native American or Pacific Islander

Multiracial

White or Caucasian

Prefer not to answer

Other:

Sex *

Emergency Contact Information

Please provide emergency contact information below.

Emergency Contact First and Last Name *

This emergency contact is a parent or guardian *

Yes

Required

Emergency Contact Phone number *

Emergency Contact Address *

Release of Liability

By typing my name in the field below, I, for myself, do hereby release Berklee College of Music, its principals, trustees, directors, officers, agents, employees, and the staff and instructors from any and all liability, and I waive any claim for damages arising from any cause whatsoever.

Video/Audio/Photography Release

By typing my name in the field below, I hereby consent to and authorize Berklee College of Music and/or any of its vendors and their representatives to use still photographs, video footage, and audio recordings of my child in films, video, and audio presentations for associated nonprofit purposes, including a documentary film that might be developed for fundraising purposes. I hereby waive any rights to privacy or compensation regarding my authorized release of this video and audio material, and I agree to hold Berklee College of Music harmless from any and all claims relating to my authorized release of said material. I understand that usage of the video/audio may be seen/heard by the general public on Berklee's website(s) and in public or private screenings, and I understand that Berklee College of Music has full and complete rights to those images.

Participant Code of Conduct

All students are expected to abide by the Student Code of Community Standards. Due to the range of students involved in the program, there are additional policies in effect that are designed and enforced to ensure the safety and wellbeing of the students participating. Participants must abide by the following policies.

1. Possession and/or use of alcoholic beverages is prohibited, regardless of age. It is also a violation to be in the presence of or under the influence of alcohol and/or drugs while participating in the program.

2. Sexual activity is prohibited while participating in the program. Any activity which is a violation of Massachusetts General Law c.265, s.23 (commonly known as the Statutory Rape Law) regarding statutory rape and abuse of a child is unlawful and in violation of the standards. Also, please understand that by law we may be required to report this behavior to state authorities, and such behavior may also be grounds for immediate dismissal from the program without reimbursement of tuition and fees. Please note that in Massachusetts, this law defines a child as someone under the age of 16.

3. Participants must abide by the check-in policies as prescribed by their program.
Violations of these standards will be investigated swiftly and may lead to immediate removal from the program without reimbursement of fees, as well as parental notification. There is zero tolerance for violations of the alcohol and drug policy, and such violations will result in removal from the program.

4. Risk of Harm
Music therapy is not a crisis based clinical service. In case of crisis, call 911.

If through music therapy sessions a participant is deemed to be at risk of harm to self or to others, mandatory reporting obligations may apply and Berklee reserves the right to cease all services immediately.

5. Confidentiality Restrictions
Information about the client will only be released if this therapist determines risk of self-harm, if the the music therapist determines risk of harm to others, if the music therapist is informed about or suspects abuse, neglect, exploitation of a minor or of an incapacitated adult, or if the therapist believes that someone’s mental condition leaves the person gravely disabled.

Signature agreement: You have read the contents above and agree to the terms. I understand that I have the right to withhold or withdraw consent at any time without affecting my right to future care or services. This consent will remain valid for one year from the date signed. By signing your name below, you agree that your electronic signature is the legal equivalent of your manual signature on this document. *

Date *

YYYY

A copy of your responses will be emailed to the address you provided.

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