APPLICATION

HIGH NOTES MUSIC PROGRAM

Application form
This initial application is for 10 sessions after which you will have to reapply (with another form) Application and reapplication doesn't guarantee acceptance as we rely on funding from various sources. Please fill in the application with as much detail as possible to help us make a well informed decision.

FYI, the value of the 10 weeks lessons are approximately $500.
Full Name of applicant*

First NameLast Name
Current Age*
Street Address*
Unit or apartment number (if applicable)
City, Province, Postal Code*
E-mail*
Phone Number: Best one to contact you*

Area CodePhone Number
Have you been touched by mental illness?

NoYesI think soI prefer not to say
Main reason for applying*
Choose all that apply to you:*

I already know how to play an instrumentI have never taken instrumental music instruction beforeI have a piano or keyboard that I can practise onI prefer to learn to play the pianoI prefer to learn to play guitarI know how to read musicI prefer to take part in a group singing session (please send me more information)I am more interested in classical musicI am more interested in current musicIf accepted, I would like to be considered for a subsidized instrumentI prefer lessons on the following instrument (not listed)Other
Preferred Instrument/class:
PLEASE INDICATE YOUR FIRST CHOICE CLASS:*
Do you want an in-person lesson?

YesNo
Please answer the following to help us determine the best teacher/studio for you*

I have my own transportation and am willing to travel a reasonable distanceI will be using public transportation to get to my lessonsI rely on someone else to take me to the lessonsI am not able to travel and need a teacher to come to me (this option may take longer)
Please tell us your closest major intersection, city and province*
What is your availability (for a 30 minute music lesson)?*

I am flexible and will take whatever slot I getWeekday morningsWeekday eveningsSaturdays 10:00 am-1:00 pmSaturdays 1:00-4:00 pmOther possibilities:_____________________________________________I would prefer an online lesson
Additional information to support your application to the program:
Optional Reference

Could be a mental health care professional, social worker or anyone who can vouch that participating will benefit you.
Reference #1 Name, Phone, Email & Relationship to you
SELECT ALL TO BE CONSIDERED FOR THE PROGRAM*

If accepted I am committed to attending my weekly lessons and will give at least 24 hours notice if unable to attend my lesson as scheduled.I understand that the registered charity HIGH NOTES AVANTE is paying for the lesson fees, material and rent and will still have these expenses if I don't communicate my absence in advance. Therefore, they can discontinue the lessons if they find I am not being respectfulI agree to follow the code of conduct rules as outlined in HNA's policy letter AND/OR the individual teacher or studios policies as approved by HNA (to be sent to me)
Date

MonthDayYear
Date
HOW DID YOU HEAR ABOUT THE HIGH NOTES MUSIC PROGRAM?*

social media postmental health organizationteacherbrochureradioTVdirect email from HNAword of mouthI was referred by my health care professionalOther
Thank you for applying to High Notes Music Program

We are so excited to meet you and will be in touch as soon as possible.
ADMIN ONLY ASSIGNED TEACHER
FINAL LESSON TIME
DATE SURVEY SENT
ADMIN ONLY:
DATE 2nd SURVEY SENT
DATE Reapplication form sent
Should be Empty:

HIGH NOTES MUSIC PROGRAM

Optional Reference

Thank you for applying to High Notes Music Program