Duo Registration Form

Caregiver Email

Part A - About the Singer with Dementia

First name

Last name

Preferred Phone

Address

Singer Experience (check one):

I've sung in a vocal group.

I haven’t sung in a group before, but I can carry a tune.

Describe mobility issues (if any)

Part B - About the Caregiver

First Name

Last Name

Phone (if different than singer's)

Address (if different from singer's)

If something happens to you, the Caregiver, on site, who should we call? (Name, Phone#, Relationship)

Describe mobility issues (if any)

Participation Agreement (Required)

This is a collaborative program with my loved one, not a respite program.

There will be no medical personnel available during the rehearsals and/or performances. I understand that I, the caregiver, must remain in the rehearsal room throughout the duration of the session.

This is not a music therapy program. (Music therapy is the use of music interventions to accomplish individualized goals within a therapeutic relationship by a board-certified professional.)

We give Melodies in Mind permission to use photos, videos or audio recordings of us for the chorus's publicity, educational and promotional materials.

Consistent attendance helps everyone feel confident and connected. While we know that life events may occasionally arise, we appreciate your intent to attend rehearsals regularly and to be part of our public performance.

Space is limited. If we're full, we'll place you on a waiting list and let you know when an opening occurs.

Participation in the 10-week season is $50 per couple. We'll send you link to make the payment. This fee partially covers rehearsal space and refreshments, music-related expenses, and other program costs. If the fee presents a hardship, please talk to us.

Caregiver's Signature and Date

(Type your full name as your electronic signature.

A payment link will be sent subsequently.)

Full Name and Date

Duo Registration
Singer with Dementia and Caregiver

If you can carry a tune, that's all you need.
Your duo will become a trio, as you will be paired with a volunteer singer who will help the person with dementia with musical issues as needed, such as page turning, finding the place in the song, or just exchanging smiles.

Duo Registration Form

Caregiver's Signature and Date

Duo Registration Singer with Dementia and Caregiver

If you can carry a tune, that's all you need. Your duo will become a trio, as you will be paired with a volunteer singer who will help the person with dementia with musical issues as needed, such as page turning, finding the place in the song, or just exchanging smiles.

Duo Registration Form

Caregiver's Signature and Date

Duo Registration
Singer with Dementia and Caregiver

If you can carry a tune, that's all you need.
Your duo will become a trio, as you will be paired with a volunteer singer who will help the person with dementia with musical issues as needed, such as page turning, finding the place in the song, or just exchanging smiles.