Today's Date:*
Name:*
Email Address*
Address:*
Area(s) you are near at work/home (for placement proximity):*
Contact phone numbers:*
Profession:*
Age: (If you are under 18, an adult must accompany you to every performance.)*
Brief overview of your music/performing experience:*
When are you available to begin?*
What days/times are you available for performances?*
Do you prefer a group or an individual home-bound senior?
Group
Individual
Both
Do you have a senior facility/homebound senior adult in mind?
When is the best time to contact you?
Morning
Afternoon
Night
How did you hear about Music for Seniors?
Please give us one personal reference (not a family member) including the Name, Home phone, Other phone, and Relationship to you:*