Community Class Registration

Music For Everyday Life - Nicholas Center

Community Class Registration - Single Session
Community Class Schedule*
Name*

First NameLast Name
Preferred nickname:
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Have you signed up for an EE Music Class before?*

Accessibility & Support Needs
Do you use any mobility aids?

YesNo
If "yes", check all that apply:

WheelchairWalkerCaneOther
If "other", could you share more?
Do you use any mobility aids?

YesNo
If "yes, what do you use?
Are there any specific accommodations or supports that would help you fully participate?
Medical & Safety Information

*Only if relevant for participation
Allergies (food, environmental, medication):
Medications (if necessary for staff awareness):
Seizure history or other medical considerations:
Any restrictions or health concerns EE should be aware of?
Emergency Contact & Support Information
Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.
Email
example@example.com
Secondary Emergency Contact

(Optional)
Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.
Email
example@example.com
Support Staff (if applicable)

(e.g., DSP, Case Manager, Family Member)
Name

First NameLast Name
Role
Phone Number
Please enter a valid phone number.

Participant/Parent/Guardian Consent Agreements
Liability Waiver

By participating in Making Music, Together, I understand and acknowledge that this is a group music program involving the use of instruments, movement, and other activities that may carry inherent risks. I voluntarily assume full responsibility for any personal injury or property damage that may occur during my participation in this program.

I hereby release and hold harmless Especially Everyone, its staff, facilitators, volunteers, and partnering organizations from any and all liability, claims, or demands arising out of or in connection with my participation in the class.

I certify that I am voluntarily participating, and that I am physically and emotionally able to do so. If I have any concerns about my ability to participate safely, I will notify the organizers in advance.
Please check all boxes to proceed:*

I have read the liability waiver above.I give permission for Especially Everyone to take photos and/or videos for promotional purposes.I confirm that the information provided is accurate to best of my knowledge.I understand the program structure and agree to participate in a way that fosters a positive and inclusive environment.
Signature (Participant, Guardian, or Caregiver if applicable)*

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Date*

MonthDayYear
Date

My Products*

Music for Everyday Life120-minute Community Class

$120.00 Quantity

Total

$0.00

Music For Everyday Life - Nicholas Center