Location where you wish to study at:
Mondays, Fridays at the Mission District Branch - Mayu Kawata
Tuesdays at the Richmond District Branch – Ian Wilkerson
—Mission District BranchRichmond District Branch

Child’s Name*:
 

Prefers to be called:
 

Child’s Date of Birth* (i.e. 05-30-2010):
 

Gender*:
—FemaleMale

Parent Name*:
 

Address – city – zipcode*:
 

Home phone:
 

Cell Phone*:
 

Email*:
 

Caregiver Name:
 

Address – city – zipcode:
 

Home phone:
 

Cell Phone:
 

Email:
 

Emergency Contact*:
 

Relationship*:
 

Phone number where most likely to be reached*:
 

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Please list all special health issues, including allergies that your child has:
 

Is your child on a special diet?* —Yes No

If yes, please describe:
 

Does the child have a current diagnosis?* —Yes No

If yes, what is the diagnosis?
 

Who gave this diagnosis?  

Is the child on any medications?* —Yes No

If yes, please write down the types of Medication

Does the child have any allergies or sensitivities?* —Yes No

If yes, please specify:
 

Are there any precautions we should take in working with the child?* (i.e. seizures, biting, self-injurious behavior, etc.) —Yes No

If yes, please specify:
 

Does the child participate in any other therapies?* —Yes No

If yes, please specify:
 

Has the child had any previous musical experience or exposure?* —Yes No

If yes, please specify:
 

Do you believe the child has any particular musical aptitude?* —Yes No

If yes, please specify:
 

Are there any musicians in the child’s immediate family?* —Yes No

If yes, who?
 

Have you noticed that the child has any musical preference?* —Yes No

If yes, please specify:
 

What benefits do you anticipate from music therapy?*

Gross motor

Have you noticed that the child has any gross motor difficulties?* —Yes No

Is the child fully ambulatory?* —No Yes

Does the child require any physical assistance?* —Yes No

Does the child have full use of all of his/her limbs?* —No Yes

Fine motor

Have you noticed that the child has any fine motor difficulties?* —Yes No

Is the child able to perform fine motor tasks with both hands? (i.e. eat with utensils, button a button, hold a pencil)* —No Yes

Does the child frequently drop items or have difficulty holding objects?* —Yes No

Oral

Does the child have any feeding issues?* —Yes No

Does the child have any respiratory issues?* —No Yes

Sensory

Have you noticed that the child has any sensory issues?* —Yes No

Does the child resist physical support?* —No Yes

Does the child engage in any repetitive behaviors?* —Yes No

Does the child have any deficits in hearing, vision or other senses?* —Yes No

Does the child have any sensitivities to/or extreme preferences for particular sounds?* —No Yes

Is the child over-stimulated by sounds, lights or crowds?* —Yes No

Receptive communication/auditory perception

Has the child been diagnosed with any hearing difficulties?* —Yes No

If so, has an audiogram been done and what were the results?
 

Does the child have difficulty hearing sounds or understanding speech?* —No Yes

Does the child have a history of ear infections?* —Yes No

Does the child understand or react to what is being said to him/her?* —Yes No

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General comments:

This is not a registration form. A Registrar will contact you to let you know if you have been accepted to CMC’s Music Therapy program.