New Patient/rockSTAR Sign-Up Form (Salesforce)

New Patient/rockSTAR Sign-Up
Wherever you are, in-hospital or at-home, we are here to support you. Sign up today to receive a VIP ALL-ACCESS PASS to be a part of as many programs as you want or need. From 1:1 Music Therapy Sessions, Weekly Group Music & Art Therapy Sessions, rockSTAR Song Requests, and Livestream Performances with special shoutouts from stage, we are here to provide ongoing support and cheer for you! Open to all-ages, whole-family care & free for all patients and families.
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.*

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City/State

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is the referred rockSTAR living with an acute or chronic illness? Please describe:*
Treatment Facility
rockSTAR DOB*

MonthDayYear
Date

Anything else you'd like us to know? Comments/Questions?
Are there any other programs you're interested in?

Group Music + Art Therapy Session1:1 Music Therapy SessionrockSTAR Song Request
Send us a photo of yourself to share with our bands/artists!

Cancelof
May we share your photo with our artists and publicly (website/social media, etc)*

YesNo
If Yes, what is your social handle(s) so we can tag you?
How did you hear about us?*
Tell us how you heard about us...
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