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– Facility / Residence Information
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Residence Name
*
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Residence Address
*
Required
Street Address
City
Postal Code
Scope of care offered
*
Required
Long-term care
Assisted living
Independent living
Palliative
Dementia and Alzheimers’ care
Concert space(s) available
Piano or Keyboard available
*
Required
Yes, Piano
Yes, Keyboard
Yes, both
No
Name
First
Last
Email
*
Required
Phone
*
Required
Best time to call you during the day
*
Required
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Hours
Minutes
AM/PM
AM
PM
AM/PM
Frequency request for concerts (within 12-month period)
*
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4 (min)
5
6
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8
9
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Need to discuss
Current musical interests of residents
*
Required
Please describe the generally preferred musical tastes and interests of your residents. (eg: Jazz, Classical, Folk, Traditional Chinese, South Indian drumming, etc)
Current frequency of performances and entertainment
*
Required
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