Musician In Residence Information Request Form

Name*

First Last

Email*

Phone*

Facility Name*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

How many musicians-in-residence is your facility interested in hosting?*

One
Two
Three or more

When would you like this program to begin?*

What instruments are best suited to your community?*

Check all that apply.

How frequently would you require the musician(s) to present concerts?*

Once a week
Twice a week
Three times a week or more

For what populations in your facility would regular performances be scheduled?*

Check all that apply.

Assisted Living
Independent Living
Dementia Care
Skilled Nursing
Other

If other, please specify:

What sort of activities are you most interested in programming?*

Check all that apply.

Door to door performances
Music related lectures
Teaching activities
Open practice sessions
Special events

Do you currently offer music related activities in your community?*

Yes
No

What music activities do you currently have in your community?*

Check all that apply.

Live performances
Video performances
Recorded music
Classes or educational opportunities
Lectures on music related topics
Other

If other, please specify:

If you currently have musical activities in your community, what additional benefit do you see provided by a Musician-in-Residence?

What are your primary motivations for including a Musician-in-Residence in your community?*

Check all that apply.

High quality live musical performance
Therapeutic benefits of music for residents and staff
Opportunity for relationship with younger generation
Interactive, immersive creative experience
PR/marketing/recruitment

Does your facility have a piano or keyboard instrument in good condition?*

Yes
No

Please describe your keyboard instrument.

If possible, list the manufacturer (e.g. Steinway, Mason & Hamlin, Hammond), and the type of instrument (e.g. upright piano, grand piano, harpsichord, electric organ).

Do you require musicians-in-residence and other employees to receive a flu shot?*

Yes
No

Do you require musicians-in-residence and other employees to undergo a pre-employment a drug test and background check?*

Yes
No

Will you provide your Musician-in-Residence with full orientation and new employee training upon moving in?*

Yes
No

Are you able to provide transportation assistance (e.g. drop-off at Light Rail or bus stop)?*

Yes
No

Are pets allowed?*

Yes
No

Are spouses/partners welcome to live in your community?*

Yes
No

Please list any other important information here:

Phone

This field is for validation purposes and should be left unchanged.

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