APPLY

First Name *

Last Name *

Street Address *

City, State, Zip *

Phone *

Email *

Emergency contact number *

Emergency contact name *

Have you been diagnosed with *

PTSD

Depression

Instrument choice *

Rhythm Guitar

Lead Guitar

Bass Guitar

Lap Steel

Favorite music style (select all you like)

On a scale of 1 to 10 how does PTSD affect your daily life? *

On a scale of 1 to 10 how does depression affect your daily life? *

If approved for this program can you guarantee 30 minutes per day to practice? *

Yes

No

Any physical limitations that may affect you in this program?

What do you hope to gain from your participation in this program?

Lesson Location preferences (select all you'd be willing to travel to) *

Millsboro, De

Dover, DE

Federalsburg, MD

Salisbury, MD