Play it Back Music Intake Form
First Name/Nombre
Last Name/Apellido
Age/Anos
Email
Phone Number/Numero de Telefono
Pronouns/Pronombres
Hospital Affiliation/Alifiliacion al hospital
Preferred method of communication/
Método preferido de comunicación
Phone Call/Numero de Telefono
Email
Text/Texto
Person referring to music program/Quien se esta registrando
Self/yo mismo
Parent/Caregiver/Cuidador(a)
Friend/Amigo(a)
Hospital Representative/Personal de Hospital
Other/Otro(a)
Please Specify/Especifar
Name, email and phone number for hospital contact/ Nombre, email, y Numero de Telefono
Please select ALL music genres that interest you (If self-referral)/Preferencial Musica:
Pop
Rock
Hip Hop
Reggae
Jazz
Classical
Folk
Blues
R&B
Rap
Country
Alernative
Musical Theater
Other
Please Specify/Especifar
I am interested in: (select as many as you'd like)/Interesando(a) en
Music Writing/Escribiendo Musica
Singing/Canto
Playing An Instrument/Tocar un Instrumento
I have no idea, I just want to have fun/Quiero Divertirme
What would you like us to know about you?/Cuentanos acerca de ti
If under 18 form must be signed by a parent or guardian/Menor de Edad
Parent/Guardian First Name - Guardian(a) Nombre
Parent/Guardian Last Name - Guardian(a) Apellido
Parent/Guardian Email - Guardian(a) Email
Parent/Guardian Phone Number - Guardian(a) Telephono
Contact Information