Client's Legal Name
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First Name
Last Name
Client's Preferred Name (Nickname)
Client's Preferred Pronouns
Client Date of Birth
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MM
DD
YYYY
Parent/Guardian Name and Relationship to Client (if client is a minor)
Client (or Guardian) Email
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Client (or Guardian) Phone
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(###)
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####
Client (or Guardian) Mailing Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Emergency Contact (can be guardian if client is a minor)
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First Name
Last Name
Emergency Contact Relationship to Client
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Emergency Contact Phone Number
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(###)
###
####
What services are you interested in?
How did you hear about us?
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Please take a moment to let us know of any concerns or questions you may have.
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This is an opportunity to clarify anything you may be curious, confused, or concerned about.
Policies and Guidelines Agreement
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I am an adult, or the parent/legal guardian of the client, willingly enrolling in therapy or wellness lessons through Pen Bay Music Therapy LLC. I have read the Pen Bay Music Therapy LLC policies available online, or presented to me, and I clearly understand and agree to the payment and cancellation procedures described within. By signing below, I acknowledge that I understand and agree to all policies, guidelines and conditions set forth above.
Participation Expectations
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Participation: I hereby consent and agree, for myself/my minor child, to participate in music therapy and/or other related services (e.g. wellness lessons) provided through Pen Bay Music Therapy. I understand that I am fully responsible for myself/my child until such time that my/my child’s session or other Pen Bay Music Therapy service begins, and that I also am responsible for myself and/or my child immediately upon the conclusion of my/my child's session. This includes, but is not limited to, transportation to and from the Midcoast Music Academy where sessions may be held, all time spent waiting for the scheduled session to begin, and/or waiting for pick-up following a session. In consideration for Pen Bay Music Therapy LLC accepting me/my child as a client, I do hereby for myself, my spouse, my children, our heirs, personal representatives and assigns, expressly release and forever discharge Pen Bay Music Therapy LLC, its officers, agents, and employees of and from any liability and all claims, suits, or causes of action arising from or as a result of my/my child’s participation in Pen Bay Music Therapy LLC programs, including, without limitation, injuries or damages sustained by myself and/or child on property managed by Midcoast Music Academy.
In the Event of an Emergency
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I hereby authorize and request Dan Wenger, Pen Bay Music Therapy LLC and Midcoast Music Academy to provide or secure me/my child to receive emergency treatment at a hospital and/or from a licensed physician should the need arise. I hereby give my consent for Dan Wenger, Pen Bay Music Therapy LLC, and Midcoast Music Academy to seek necessary emergency medical treatment for me/my child, and for me/my child to receive such emergency medical treatment, which may be deemed necessary or advisable in the event of injury, accident or illness. I further understand that the emergency contact listed will be called immediately if any emergency arises and I accept financial responsibility for all such medical treatment that may be provided.
E-Signature
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