Telehealth_Consent_Form If you are a human and are seeing this field, please leave it blank. Primary Participant (First and Last Name) Age (If under 18, otherwise optional) Additional participants name and age (If applicable) Additional participants name and age (If applicable) Additional participants name and age (If applicable) Guardian first and last name if not the primary participant Any special needs or accommodations we need to know about so you or your loved one can successfully participate Preferred music/artists City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Phone Please check all courses (25$ per course, per person) Connecting Our Voices-Wednesdays 6:30-7:30pm Your Music, New Friends-Children’s Group- Tuesday Mornings 10:30-11:00AM Your Music, New Friends- Adult Group- Friday Afternoons from 3:00-3:30PM COMT Virtual NeuroChoir- Thursdays 11:00am-12:00pm Memories Choir- Tuesdays 10:00-11:00am Sprouting Melodies- Wednesdays 10-10:30am Babble, Bounce, and Bond: Music for Infant and Baby-Mondays 10-10:30am Sentimental Journeys! Thursdays 10:00-10:30am Email What you need to participate: An internet connection, an email account, and a Zoom account Computer, tablet or smartphone with video camera and audio input (built in microphone or otherwise) & output (built in speaker/headphone jack) Headphones are ideal but not required *let us know if headphones are not possible due to physical, sensor and/or safety issues and we will work with you I have a zoom account I will be getting a zoom account I am not sure I have all the necessary technology or equipment to participate, but can acquire them with recommendations/assistance I have all the necessary technology equipment to participate What would you like to get out of participation in COMT Virtual MT Programming? By clicking submit, you are agreeing to the terms of the Telehealth Consent Form at the top of the page and agree to pay $25 per person per course on the Paypal link provided.
