Register your student

School *

Name of person registering student *

First

Last

Position *

Email of person resgistering student *

Name of student *

First

Last

Date of Birth *

Year level *

Room number and teacher (if applicable)

First caregiver name *

First

Last

First caregiver email *

Second caregiver name

First

Last

Second caregiver email

Please confirm that the school has 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.

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. *

Is this student currently accessing music therapy anywhere else?

Please note that in compliance with Music Therapy New Zealand's Code of Ethics, we do not generally work with participants who are already working with another music therapist. However, from time to time it may be possible to work in collaboration with another music therapist where the service provisions differ.

Emergency contact name *

First

Last

It is LMC policy to hold details of an emergency contact for all the tamariki that we work with. This may be a friend or family member that does not live in the same household.

Relationship to student *

Emergency contact phone number *

Name