Name of Participant: *

First Name

Last Name

Address of Participant: *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth: *

MM

DD

YYYY

Name of Parent/Caregiver: *

First Name

Last Name

Address (if different) *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name of Worker (If applicable): *

First Name

Last Name

Home Phone: *

(###)

###

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Cell Phone: *

(###)

###

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Name *

First Name

Last Name

Phone *

(###)

###

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Program Location? *

Client's Residence

Tim Sheffield's Home Studio

Name

First Name

Last Name

Phone

(###)

###

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I understand that I am signing up for the entire session: *

Yes, I Do.

I agree to pay the amount specified for the Program: *

I Agree

Let’s Make Music Is On Social Media

Please let us know where we can use pictures of the participant:

Facebook

Instagram

Twitter

Website

PowerPoint During Presentations

Transfer of Care: *

We are committed to offering quality programming for our clients. We believe it is extremely important to provide a safe, therapeutic, and caring environment for our clients to grow. Please note that individuals must be able to demonstrate a basic ability to care for their personal needs while attending programming. To ensure the safety of your loved one, we do not offer transfer of care. Staff are unable to assist with transfers, diaper changes and lifts unless a qualified PSW is on site.

I have read and understand the Transfer of Care Policy