Music Therapy Registration Form

Music Therapy Registration Form

At KYCC Recovery Services, by Rhythy and Truth
This is an registration form for 12-week music therapy workshop for youth. Participants are not required to attend all 12 workshops.

Please answer all required questions.

You must provide emergency contact in order to register.
My Name*

First NameLast Name
Age *
My Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Saturday, April 11thSaturday, April 18thSaturday, April 25thSaturday, May 2ndSaturday, May 9thSaturday, May 16thSaturday, May 23rdSaturday, May 30thSaturday, June 6thSaturday, June 13thSaturday, June 20thSaturday, June 27th
Should be Empty: