Breaking Free: The Transformative Power of Music Improvisation

Who is this form being filled out by?*

Participant

Parent

Relation Information

How are you related to the participant?*

Relation First Name*

Relation Last Name*

Relation Email*

Participant Information

Participant First Name*

Participant Last Name*

Participant Email Address*

Participant Phone Number*

Participant Birthdate*

Participant Mailing Address*

Country

Street

City

Region

Postal Code

What High School is the participant attending? *
type school name and select from the drop-down list

What year would the participant graduate from high school?*

What school/college is the participant attending? *
type school name and select from the drop-down list

Participant Musical Background

Instrument

Have you taken private lessons?*

Yes

No

If yes, for how long?

Name of Private Teacher*

Email Address of Private Teacher

Are you interested in the "Intro to College Life and Music" Pizza Lunch from 12 - 1p.m.? *

Yes

No

Are you interested in receiving Continuing Music Therapy Education Credits (CMTE)? *

Yes

No

What is your MT-BC number?

By checking this box yes, I hereby grant permission and the rights to use my son/daughter's image, likeness and sound of his/her voice, and any specific quotes, as recorded on audio, video or camera, either digitally or on tape/film ("Material") to University of the Pacific, without payment or any other consideration. I understand that the Material may be edited, copied, exhibited, published, or distributed and I waive the right to inspect or approve the finished product wherein the Material appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the Material. I also understand that this Material may be used in diverse settings within an unrestricted geographic area.

Yes