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Winter ’22 Group Music Therapy Registration

Mondays, 1 PM January 10- February 21 NO CLASS MLK DAY, JANUARY 24.

Tuition for the 6-week session is 130.00 (including $10 registration fee), by January 3.

Checks payable to Mid-South Music Therapy Services, or via PayPal (midsouthmusictherapy@gmail.com).

Child’s Name

First

Last

Age/ Date of Birth

Parent/Guardian Name

First

Last

Mailing Address

City/State/Zip

Phone Number

E-mail Address

Preferred Method of Contact

What is your child’s diagnosis?

Please tell me anything about your child that you think would be helpful in therapy.