Address: ________________________________
State: ______ Zip: ______
Contact Person: ________________________________
Phone Number: ________________________________
Type of Facility: ________________________________
Please describe the physical and mental health of your children:
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
Please describe how Music That Heals would benefit your children:
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____________________________________________________
____________________________________________________
____________________________________________________
Does your facility have any special events? Please describe them:
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
What would the average attendance be for a Music That Heals performance? Please include parents and staff:
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
Please include any additional comments that might be helpful for us to know:
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
Please mail your request to:
Music That Heals
P.O. Box 950205
Fort Tilden, NY 11695
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In Collaboration with Hospital Audiences Inc.