Music Therapy Registration Form

* Required Fields

Parent/Guardian Information

First Name

Last Name

Secondary Parent/Caregiver First Name

Secondary Parent/Caregiver Last Name

Address

Address 2

City

State/Province

Zip/Postal Code

Home Phone

Cell Phone

Work Phone

Please add me to your mailing list

Location Preference

Select Location

Child Information

Child Name

Birthday

School Attending

How did you hear about the music therapy program?

Information Regarding the Registrant

Hearing loss level

Device used (if any)

Please tell us any concerns you currently have with your child's language development.

Does your child have any other needs that the Therapist should be aware of?

Child's Preferred Mode of Communication

Has your child participated in music therapy previously?

YesNo

* Has your child participated in music therapy previously? is required.

If so, where?

Has your child participated in FHSR's MTME programming?

YesNo

* Has your child participated in FHSR's MTME programming? is required.

If yes, which program?

Would you like to bring a Sibling?

YesNo

* Would you like to bring a Sibling? is required.

Name and age of Sibling who would like to attend.

Privacy Policy
We take precautions to protect your information. We collect credit card or bank account information, names, addresses, and other data related to your transaction when you make a payment through our site. We use this information to process your payment.

Terms/Conditions
By submitting your payment, you authorize us to charge the account above for the amount specified in the Transaction Amount field. Account information for Recurring Pledges/Monthly Giving is encrypted and stored securely via SafeSave™ for automatic processing of your future payments. Notify us at anytime if you wish to discontinue your pledge.

For more information go to FHSR.org
or email us at [email protected]
The Foundation for Hearing and Speech Resources
PO Box 180018
Chicago, Il 60618