Referral Form

First name

Last name

Phone

Title

Agency/Affiliation

Relationship to child

Parent/Guardian Name

Parent/Guardian Phone Number

Parent/Guardian Email

Parent/Guardian Occupation

Parent/Guardian Relationship to Child

Secondary Parent/Guardian Name

Secondary Parent/Guardian Phone Number

Secondary Parent/Guardian Email

Secondary Parent/Guardian Occupation

Secondary Parent/Guardian Relationship to Child

Child’s Name

Child’s Preferred Name (If different from above)

Child’s Date of Birth

Child’s Preferred Pronouns

Child’s primary language

Child’s school

Child’s mailing address

Child’s Emergency Contact Name and Phone Number

What makes this child/youth a good fit for JMB?

What do you hope the child/youth will gain from involvement with JMB?

How would you describe the child/youth?

What are some of the child/youth’s favourite musical interests?

What is the child/youth’s experience with music, if any?

Are there any barriers to the child/youth attending lessons? (Work schedules, transportation, etc)

Are there any medical/allergy considerations we should know about?

Is the child involved in any other musical ensembles?

Does the child/youth have access to other funding for extracurricular activities? If so please list source and amount

I hereby apply to Justin’s Musical Bridge, hereafter referred to as “The Agency” to make their services available to the child/youth listed above.

In consideration for this service and other valuable consideration provided to my child by the Agency, I release all responsibilities and liabilities in connection to their services provided in good faith, to my child. I permit The Agency to release any relevant information, including my/the child’s personal information, to the selected musical school for the purpose of registration.

I understand that the collection of personal information about my child will be held in strict confidence and is to be used solely for the purposes of administering the program. I am aware that music instructors have no knowledge of my child’s involvement with The Agency

unless I or my child wishes to disclose otherwise.

I further agree that information about my child may be shared, at the discretion of The Agency, with my child’s instructor so that my child’s safety and needs can be met. I understand that The Agency is under no obligation to provide my child with music lessons and that this application is the property of The Agency. I also agree that should there be no available space at present, my child can remain on a waitlist and be contacted in the future to commence programming through The Agency.

I have read and understand this referral and agreement. I hereby request that the child listed above be considered for acceptance to Justin’s Musical Bridge.