June Jessee Memorial Foundation · JJMF Music Therapy Event Form

Sign-up for Music Therapy here

Music Therapy Dates *

Check the dates you can attend. Please note all times are indicated in Central Daylight Time/Central Standard Time so you may convert to your local time zone.

Saturday, November 16th at 9:00AM - 10:00 AM CT

Parent/Caregiver Name *

First Name

Last Name

Parent/Caregiver Email *

Verify Email *

Parent/Caregiver Phone *

Parent/Caregiver Address *

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Name and DOB of child with medical condition *

Siblings' Names and DOB

Is there any information you would like to share with JJMF or the music therapist about your child?

Photography Permission *

JJMF utilizes photos taken during music therapy sessions for marketing purposes.

Permission granted for photo use

Opt out of photo use