Patient/rockSTAR Sign-up
All SMS and email communications will be conducted in compliance with HIPAA, GDPR, and TCPA laws. HIPAA + GDPR COMPLIANT // Melodic Caring Project (MCP) is committed to and has implemented staff education and technical safeguards to prevent unauthorized use or disclosure of information as well ensure its devices, services, websites and data systems (collectively “Products”) are compliant with the regulations and conditions set forth in the Health Insurance Portability and Availability Act of 1996 (HIPAA) and (GDPR).
By checking this box I certify that I am at least 18 years of age or am the parent or legal guardian of the person listed on this form.
*
Check Here
rockSTAR Name
First Name
Last Name
rockSTAR Parent/Guardian Name
First Name
Last Name
Email
*
example@example.com
Confirm Email
*
example@example.com
Phone
*
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is the referred rockSTAR living with an acute or chronic illness? Please describe
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Treatment Facility
Child Life Specialist, Social Worker or Music Therapist
rockSTAR DOB
*
-
Month
-
Day
Year
Date
Gender (optional)
Please Select
Male
Female
Prefer not to answer
Would you be interested in Sibling and Family Support Services?
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Yes
No
Maybe
Would you be interested in a Virtual Music Therapy Session?
*
Yes
No
Maybe
Favorite Songs/Artists?
*
What's your favorite type of music? Your favorite artists/songs?
0/32768
Anything else you'd like us to know? Comments/Questions?
0/32768
Send us a Photo of yourself to share with our bands/artists!
Browse Files
Drag and drop files here
Choose a file
Cancel
of
May we share your photo with our artists and publicly (website/social media, etc)
*
Yes
No
If Yes, what is your social handle(s) so we can tag you?
How did you hear about us?
Please Select
Google Search
Social Media
Friend/Family
Hospital/Medical Staff
Other
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