sINgSPIRE
Sanford Participant Information Form

sINgSPIRE is a 10-week individual voice lesson program that combats cystic fibrosis
through the art of singing.

Students are paired with a professional sINgSPIRE voice instructor based upon their age, weekly lesson availability, and instructor availability. Lesson materials, music, and program aides will be provided by Breathe Bravely.

Video-Call Lessons

An innovative and impactful teaching method for sINgSPIRE. Video lessons take place via a video call platform called ZOOM. Because of this technology, student and the instructor may remain in their respective locations and still take part in the program and lessons! The student must have access to reliable Wi-Fi and a device such as an iPad, tablet, or laptop. Instructions for connecting via video call will be sent out after enrollment into the sINgSPIRE program.

Please fill out the following form so we can best get to know you!

Sanford sINgSPIRE Student Information

Student Name

First Name

Last Name

Age

Next CF Clinic Appointment

For purposes of scheduling to adhere to the study.

MM

DD

YYYY

sINgSPIRE T-Shirt Size

Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email Address

Phone

(###)

###

####

Communication Preference

What's the best way to get in touch?

Text

Email

Both

sINgSPIRE Lessons

**** Lessons (30 minutes)

*Video-Call Lessons require a reliable Wifi connection & Video device.

Video- Call Lessons - Sanford Study Participant

Lesson Availability

Please give a general time frame so we may match you with an available sINgSPIRE instructor. (example: Monday 4:30 – 6:30 p.m. / Tuesday 7:00 - 8:00 p.m / Saturday mornings)

Other comments or requests:

Previous Music Experience

Have you taken private music lessons before?

Yes

No

If yes, what type of lessons and for how long?

Example: Piano - 3yrs

Are you involved in music at your school or in your community?

(general music, choir, band, theater, etc.)

Parent/ Guardian Information (if under 18)

Name

First Name

Last Name

Parent/ Guardian Email

Parent/ Guardian Phone

(###)

###

####

Health & Emergency Contact

Please list any and all health concerns Breathe Bravely and the teacher should be aware of:

(cystic fibrosis, diabetes, asthma, anxiety, allergies etc.)

Emergency Contact

First Name

Last Name

Emergency Phone

(###)

###

####

Signature

By typing your name in the box below you acknowledge that you are enrolling yourself or your child in sINgSPIRE - a program by Breathe Bravely specifically for people with cystic fibrosis and that all the information given is accurate.

sINgSPIRESanford Participant Information Form

Please fill out the following form so we can best get to know you!

Info

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sINgSPIRE
Sanford Participant Information Form