Infinity Music Therapy Services Online Group Intake

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* 1. Participant's name (first and last)

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* 2. Participant's age

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* 3. Does the participant have any disabilities, mental health disorders, or any other needs we should know about?

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* 4. Parent/guardian name(s) (first and last)

Name 1

Name 2

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* 5. Cell phone number(s)

Primary contact

Secondary contact

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* 6. E-mail address(es)

Primary contact

Secondary contact

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* 7. Do you have any of the following materials available to you?

Shakers (maracas, egg shakers or even Tupperware filled with rice or beans)

Tambourines or Jingle Sticks

Drums (or even a pot or plastic bin with a wooden spoon)

Jingle Bells

Rhythm Sticks (or two wooden spoons or rulers)

Xylophone

Other (please specify)

Online Group Options:
Visit http://www.infinitymusictherapy.com/classes-groups/ for full course descriptions
All groups are LIVE!

Music History/Appreciation class (for elementary age)
Offered Tuesday/Thursday from 1:00pm-1:40pm EST
Dates: April 7, 9, 14, 16, 21, 23, 28, 30

Let's Make Music! (for families with children ages 3mos-10yrs old and beyond)
Offered Monday, Thursday, Friday at 9:00am-9:40am EST
Dates: April 6, 9, 10, 13, 16, 17, 20, 23, 24, 30

Sing and Sign (ages 3months and up! We welcome all ages)
Offered Monday/Wednesday from 3:30pm-4:10pm EST
Dates: April 6, 8, 13, 15, 20, 22, 27, 29

Song-writing for High School Students (for ages 13-19)
Offered Monday/ Thursday from 4:00pm-5:00pm
Dates: Session 1: April 6, 9, 13, 16
Session 2: April 20, 23, 27, 30

Open Mic Night (all ages) FREE!!!-Goodwill Donations Accepted
Offered Saturday, April 18 7:00pm-7:40 EST (time will be extended if we have enough sign-ups)

Music History, Let's Make Music, and Sing and Sign are offered at a rate of $10/single session, or $35 for four sessions. Please feel free to mix and match. Song-writing is $50.00/series or $85.00 for both sessions. Do you have multiple children or participants at home? We've got you covered! This pricing is PER device log on. We will accept additional goodwill donations to help us stay open during COVID-19 for any additional individuals you register.

By submitting this form, I understand that I am agreeing to receive a text message from IvyPay to the provided number(s) in order to pay fees for services rendered. I will receive an email and text on how to sign into the group and other information upon processing a payment.

If you have any questions regarding this document, please contact Jona Jeffcoat, MT-BC, Director of services at jona@infinitymusictherapy.com or at (860) 518-5557.

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* 8. What dates are you registering for each class?

Music History/ Appreciation (Elementary)

Song-Writing

Let's Make Music

Sing and Sign

Interactive Sing-a-long

Open Mic Night

Infinity Music Therapy Services Online Group Intake

Question Title

* 1. Participant's name (first and last)

Question Title

* 2. Participant's age

Question Title

* 3. Does the participant have any disabilities, mental health disorders, or any other needs we should know about?

Question Title

* 4. Parent/guardian name(s) (first and last)

Question Title

* 5. Cell phone number(s)

Question Title

* 6. E-mail address(es)

Question Title

* 7. Do you have any of the following materials available to you?

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* 8. What dates are you registering for each class?

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* 9. Please share any additional relevant information about the participant including favorite songs, artists, and other interests.