Name of Participant *

First Name

Last Name

Participant's Date of Birth

MM

DD

YYYY

Parents/Caregiver/Participant's representatives *

First Name

Last Name

Funding Type *

Please note that we are not NDIS provider.

Private, not funded by NDIS

NDIS Self-managed

NDIS Plan-managed

Privacy Statement *

By submitting this form, you agree to share your information with New Song Music Therapy for the purpose of registering interest in the El-Rhythm music therapy Group. Your personal details will be kept confidential and used only to contact you regarding this program. We respect your privacy and will not share your information with third parties. If you have any concerns or wish to withdraw your interest, please contact us at angeltsangsmusic@gmail.com.

I agree to share my information with New Song Music Therapy for the purpose of this program and understand that my data will be kept confidential.