APPLICATION

HIGH NOTES MUSIC PROGRAM

Application form
The High Notes Music Wellness group class will explore a variety of music making through improvisation, singing, and open discussion within a group setting. Although therapeutic in nature it is not therapy.

Please note: This program is a recreational music wellness group and is not a substitute for individualized or autism-specific music therapy services. Participants should be able to engage in group discussion and shared activities with peers, without the need for individualized support or therapeutic accommodation.

If you are seeking individualized or autism-specific music therapy support, please contact us directly to explore appropriate service options
Terms and Agreement Statement*
I understand that by writing my name in this box, I acknowledge that the process of music making and discussion may trigger strong emotions. However, this group is a music wellness class and NOT a music therapy group.
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
Please tell us a little about your musical preferences. Include such things as favourite artists, style of music, instruments, genres...whatever you can think of.
Have you been affected by mental illness?*

YesI think soNoOther
Main reason for applying*
Choose all that apply to you:*

I love musicI like to singI like to experiment with rhythmsI know how to read musicI can play by earI am more interested in classical musicI am more interested in current musicI always have the radio onI am comfortable sharing in a groupI am shy but like to be with other people
Are you able to come to the location as advertised?*

YesNo
What is your availability (for a 50 minute class)?*

I am flexible and will take whatever slot I getFriday morningsSaturdays 1:30-2:20
Additional information to support your application:
Optional Reference

Could be anyone who can vouch that participating will benefit you.
Reference #1 Name, Phone, Email & Relationship to you
Thank you for applying to High Notes Music Wellness Group Class

We are so excited to meet you and will be in touch as soon as possible.
Should be Empty:

HIGH NOTES MUSIC PROGRAM

Optional Reference

Thank you for applying to High Notes Music Wellness Group Class