Register your student

School *

Name of person registering student *

First

Last

Email of person resgistering student *

Name of student *

First

Last

Year level *

Room number and teacher *

Student strengths and interests

Does the student already play an instrument? If so, please give details. along with any other information about musical preferences.

Reason for referral and current focus of team. Please include details of any specific medical needs. *

Primary caregiver name *

First

Last

Primary caregiver email *

Additional caregiver name

First

Last

Additional caregiver email

Please confirm that you have written or email permission from the student's caregiver(s) for them to attend music therapy

Please note that music therapy can only go ahead with caregiver permission.

Name