Altitunes New Student Registration Form

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Waiver of Claims and Release of Liability

To the best of my knowledge, all information provided below is accurate, and unless otherwise noted in detail under “Special Information,” my child has no physical, emotional or social conditions which make it dangerous for him/her to participate in music program activities with ALTITUNES Neurologic Music Therapy.

If any of the information I have stated on this form about my child changes, it is my responsibility to provide ALTITUNES Neurologic Music Therapy with those changes.

I hereby give my permission for my child to participate in all music related programs provided by ALTITUNES Neurologic Music Therapy, and I hereby release and save harmless Susie Frey and ALTITUNES Neurologic Music Therapy from any and all liability and claims which may arise from me and my child’s participation in music classes, music therapy and/or other events provided by ALTITUNES.

By submitting this form you are indicating that you are the parent/legal guardian of the child named on this form, and that you accept and acknowledge ALTITUNES Neurologic Music Therapy's stated policies and conditions for participation.

Email *

Child's First Name *

Child's Last Name *

Child's Date of Birth (Day/Month/Year)
*

*Parent/Guardian's First Name
*

Parent/Guardian's Last Name
*

Sibling's Name and Date of Birth (Day/Month/Year)

Street Address *

City *

State *

Zip *

Phone number *

What class will you be attending? *

Beboppin Babies (Newborn to Sitting)

Melodious Movers (Sitting to First Steps)

Toe Tappin' Toddlers (walking to 36 months)

Polyphonic Preschoolers (2 1/2 -4)

Music Makers (4-5)

Piano Pals (5-6)

Group or Private Instrument Lessons

Music Therapy (All Ages)

Outdoor Classes

Other:

Required

How did you hear about Altitunes? If it was a friend or word of mouth we would love to know who to thank. If you know the child's name and last initial that is even more helpful than the parent's name.

What is your child's favorite song(s) OR if you are not sure yet, what songs do you sing or play for your child?

What is your child's previous music experience? Have you attended any other music classes, instruments they have been exposed to, and better yet had the opportunity to play, etc.

Any special information about your child that Altitunes should be aware of in order to increase their enjoyment and success, such as likes/dislikes, allergies, medications, physical/sensory/social concerns, etc?

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

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