Health For A Song Membership Application

1. Consent and Representations. By checking box below I consent to independently participate in all of the Health For A Song programming (the “Program”). I understand that the Health For a Song Program:

• Is programming offering only group rehearsal of skills targeted towards support of motor, speech/cognition, social emotional, spiritual/immune functioning.
• Is lead or supervised by licensed / credentialed healthcare professionals.
• Is structured only to support those who live with conditions or diagnosis which have potential for deterioration of their quality of life if they do not maintain good practice techniques or skills they have learned in treatment or have been recommended to them by their healthcare provider.
• Is not treatment nor is it to be used in the place of treatment by a healthcare professional. No documentation will be kept or submitted regarding participant outside of registration, attendance and payment records.

By checking box below I acknowledge my desire and ability to independently participate in all of the Health For A Song programming. I represent and warrant that I and the other participants listed on the Enrollment/Registration Form are in good health and have no physical or mental conditions, ailments or disabilities that could endanger the health or safety of myself or any participant if I were to participate in the Program.

2. Participation Rules. Each participant must have written approval for enrollment and participation in the Program from his/her physician or qualified health care provider if he/she is currently undergoing, or preparing to be discharged from, treatment for any condition or diagnosis. CFMT has the right to not accept any person as a participant into the Program if CFMT determines, in its sole and absolute discretion, that such person is not appropriate for the Program for any reason or is unable to participate at a level that would be beneficial to the participant and the other participants in the Program.

By checking box below, I understand that CFMT or its staff has the right, at any time, to instruct me to leave any of the programming or premises should they decide, in their sole and absolute discretion, that my behavior and/or actions are inappropriate, a distraction to others, a threat to others or a risk to self. I also understand CFMT and its staff may cancel my enrollment in the Program at any time due to lack of payment on my account or due to the above-stated reasons. In the event my enrollment is cancelled, any fees that I have paid prior to cancellation will not be refunded to me.

3. Fees. The monthly enrollment fees for participating in the Health For A Song program are:

• Individual: $65 per month
• Family: $190 per month
• Corporate Employee: $42 per month (Must show documentation such as employee, resident, member of corporation enrolled in this program)
• Scholarship: Co-pay (Must submit to scholarship committee and receive approval in writing for scholarship funding)

4. Payment. Participant must authorize payment of all fees by ACH Direct Debit or Credit Card. After the first three months of enrollment, regular monthly drafts of the applicable monthly enrollment fee will be made from your account or credit card before the first day of each month. Any cancellation must be made in writing with at least 30 days written notice to CFMT. The initial registration fee is non-refundable as well as any other payments made prior to cancellation of the account.

By checking box below, I authorize ACH Direct Debit or Credit Card charges to pay to CFMT the initial registration fee and monthly program fees due under this agreement. Participant agrees not to revoke authorization of ACH Direct Debit or Credit Card charges by CFMT so long as any amount owed to CFMT under this agreement is outstanding. A $35 fee will be charged for declined ACH debits or credit card charges.

5. Termination. CFMT or the primary participant may terminate this agreement at any time for any or no reason, by providing at least 30 days prior written notice to the other party. In addition, CFMT may terminate the agreement and the primary participant's enrollment immediately as stated in Section 2 above. Upon termination of the agreement and/or the primary participant's enrollment, the enrollment of all other participants associated with the primary participant shall be automatically terminated as well.