thanks to a grant from the West Bay Rotary Club in Camden, we are able to offer a sliding scale of $0 - $200. Please click the “pay here” button and select the amount that works for your family.

2. registration:

fill out the registration form below to share your information with Dan Wenger (he is the only person who will see this information).

pay here

Name *

First Name

Last Name

Date of Birth

YYYY

School Attending (if applicable)

Parent/Guardian Name *

First Name

Last Name

Parent/Guardian Email *

Parent/Guardian Phone *

(###)

###

####

Emergency Contact (not parent/guardian) *

First Name

Last Name

Emergency Contact Phone (not parent/guardian) *

(###)

###

####

Needs and Preferences for Harmony for All

To help us individualize this therapeutic music group, we want to better understand your child’s unique needs and preferences. Not every question may apply, but we appreciate you taking the time to consider how we can best support your child. We hope you find these questions lead to deeper understanding and insight. Enrollment is based on a first-come, first-serve basis provided the student is elementary school aged. If you need assistance completing this, don’t hesitate to reach out to Dan@penbaymusictherapy.com.

Any allergies, particularly those that are considered severe:

Recurring injuries, if any:

Please describe chronic illness that may affect capacity for engagement:

Does your child have a seizure disorder?

*If your child happens to begin a new medication during the group, your encouraged to let the music therapist know so they can report on any changes noticed during the group.

Auditory responsiveness/reactivity:

My child may...

Avoid specific sounds and may cover ears

Dislike crowds

Be easily startled by the onset of sounds

Finds it difficult to maintain regulation in the context of several sounds

Visual responsiveness/reactivity:

My child may...

Struggle to find objects in visually stimulating environments

Not respond to people entering a room

Cover their eyes, squint, or rub their eyes (with varying frequency)

Be sensitive to lights

Watch (track) everyone when they move around the room

Benefit from visual supports (i.e. visual schedules, visually stimulating toys)

Tactile responsiveness/reactivity

My child may...

Frequently request physical touch (e.g. fist bumps, high-fives, hugs)

Dislike certain materials or textures

Avoid getting ‘messy’

Frequent the personal space of others (e.g. bumping others, close-up eye contact, refuses to leave others alone)

Struggle with transitions

Vestibular (Movement & Gravity) Responsiveness & Reactivity:

My child may...

Love movement.

Avoid movement.

Is always 'on the go'.

Climb, fall, or jump often.

Struggle to sit still.

Olfactory (Smell) Responsiveness/Reactivity:

My child may...

Extremely sensitive to certain smells

Gustatory (Taste) Responsiveness/Reactivity:

My child may...

Avoid playing instruments that require breath control due to taste, gag reflex, or textural avoidance.

Interoception (Internal Body Signals) Responsiveness & Reactivity:

My child may...

Have an unusually high pain threshold

An unusually low pain threshold

Become easily upset without a clear understanding of why

Have toilet training challenges

Proprioception (Body Awareness) Responsiveness & Reactivity:

My child may...

Have low endurance for tasks, tires easily, or collapses

Stomp when walking, prefers hard ‘high-5’s’

Hangs on their desk for support, slouches, or falls off chairs

May break objects easily, clearly accidentally

Expressive Tendencies (e.g. speech, motor, relational):

My child may...

Repeat phrases without clear understanding of their meaning (e.g. echolalia)

Fixate on specific objects, sounds, or ideas and constantly seek them out

Utilize erratic or flat (monotonous) speech contour

Struggle to sustain back-and-forth communication with others (e.g. answering yes/no questions, responding to play invitations in any way, )

Have difficulty with eye contact.

Have aggressive tendencies (e.g. hitting, biting)

Quickly resort to yelling if they feel they are being ignored

Musical Preferences: *

In the space below, please list musical artists, songs (e.g. any songs, including themes from TV shows, nursery songs, songs that they sing in the cars, etc), instruments, or expressive tendencies (e.g. humming/singing to self) that help us understand your child’s relationship to music. You can also list any previous musical experiences you would like to note and how they responded.

Thank you!

821 Commercial Street Rockport, ME 04856 207-701-7410 info@midcoastmusicacademy.com

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Midcoast Music Academy admits students of any race, age, ancestry or national origin, sexual orientation, gender, physical or mental disability, or religion to all the rights, privileges, programs, and activities, generally accorded or made available to students at the school. It does not discriminate on the basis of race, age, ancestry or national origin, sexual orientation, gender, physical or mental disability, or religion in administration of its educational policies, admission policies, scholarship and loan programs, other school administered programs, or employment.