APPLICATION

HIGH NOTES MUSIC PROGRAM

Application form
Full Name of applicant*

First NameLast Name
Current Age*
Street Address*
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 so
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 have a guitar that I can practise onI have a clarinet that I can practise onI have a saxophone that I can practise onI already have a harp that I can practise onI prefer to learn to play the pianoI prefer to learn to play the clarinetI prefer to learn to play guitarI prefer to learn to play saxophoneI prefer to learn to play the harpI know how to read musicI prefer to take part in a group music sessionI am more interested in classical musicI am more interested in current musicIf accepted, I would like to be considered for a subsidized instrumentIf 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 respectful
Preferred Instrument/class:
PLEASE INDICATE YOUR FIRST CHOICE CLASS:*
Do you want an in-person individual music lesson?

YesNo
Please tell us your closest major intersection and city
What is your availability (for a 30 minute music lesson)?

I am flexible and will take whatever slot I getWeekday morningsWeekday eveningsMondays 6-9:00 pmWednesdays 6-9:00 pm (afternoons/evening)Saturdays 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 anyone who can vouch that participating will benefit you.
Reference #1 Name, Phone, Email & Relationship to you
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:
Should be Empty:

HIGH NOTES MUSIC PROGRAM

Optional Reference

Thank you for applying to High Notes Music Program