Kian finnegan scholarship application

Child's Name *

First Name

Last Name

Caregiver Name

First Name

Last Name

Caregiver's Relationship to child

Parent

Grandparent

Guardian

Other

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Child's DOB *

MM

DD

YYYY

Best Contact Method *

By checking one of the boxes for Best Contact Method, I agree to receiving correspondence from Maestro Music Therapy

Email

Phone

Text

Referral Source

Friend/Family member

Web search

Practice website

Event

Another provider

Other

Financial Contribution *

Considering your family's current financial situation, are you able to contribute any amount towards the cost of music therapy for your child? (This in no way will impact your scholarship application.)

Yes

No

The Finnegan Family

The Kian Finnegan Legacy Scholarship is founded in memory of Kian Finnegan and his love of music. It is rooted in a sense of connection for families impacted by medical conditions and touched by music. Are you comfortable with the Finnegan family being informed about the recipient of the scholarship and, if selected, sharing your child's story (anonymously) with them? (Again, your response here will in no way impact your scholarship application)

Yes

No

Acknowledgement:

I, the undersigned, certify that the information above is accurate to the best of my knowledge.

First Name

Last Name

Date

MM

DD

YYYY