ADMIN ONLY AST Client #: Date Received: Alzheimer Society Music Project Music Update & Replacement Request Please complete the entire form using CAPITAL LETTERS and submit to Alzheimer Society staff either in person, via fax at 416-322-6656, by email at [email protected], or by mail at 1600-20 Eglinton Ave. West, Toronto, ON, M4R 1K8. MUSIC RECIPIENT: The Music Recipient is the person with dementia. First Name: Last Name: Referring Organization Name (if applicable): PRIMARY CONTACT: Select one and provide relevant details for the selected individual. o Self – Music Recipient is able to consent to the program and is representing self o Personal contact of Music Recipient – Family/friend is consenting to the program on behalf of the Music Recipient o Referring Organization – Music Recipient is not able to provide consent & no personal contact is available. The Referring Organization is consenting to the program on behalf of the Music Recipient. SKIP TO SERVICES REQUESTED. First Name: Last Name: Relationship to Music Recipient: or I am the Music Recipient Phone: Email: SERVICES REQUESTED: o Replacement Request for lost or faulty items: Select all that apply and use the attached page to indicate the Music Recipient’s music selection. Lost Broken/not working Music player o o Headphones o o Wall charger o o Charging cable o o o Music Update: Alzheimer Society Music Project will update music on a music player previously issued by the program. Please use the attached page to indicate the Music Recipient’s new music selection. © Alzheimer Society Music Project 2019. Please visit www.musicproject.ca for the most recent version of this form. PICK-UP/SHIPPING ARRANGEMENTS: Please select one and provide details. o PICK-UP – You or someone else on your behalf will collect the music player when notified by the Alzheimer Society Music Project team at one of the following locations: o Alzheimer Society Head Office (Yonge & Eglinton) o Select Toronto Public Library branches by Hours: Mon-Fri, 9 AM – 5 PM appointment only Hours: evening & weekend options available o AST at Providence (St. Clair Ave. & Warden) o AST at Reconnect (Eglinton W. & Keele) Hours: Mon-Fri, 9 AM – 4 PM Hours: Mon-Sat, 9 AM – 5 PM o SHIPPING (available to registered Referral Partners ONLY) – Ship directly to the Referring Organization at (address): NOTES/COMMENTS: Please tell us here if there is anything else you would like us to know. CONSENT: By signing below, I understand and acknowledge: ü My consent as provided in my initial Alzheimer Society Music Project application is ongoing and effective until my participation in the program ends. ü The Alzheimer Society Music Project may not be able to find all the music I may have requested. ü If requesting a replacement, any faulty items must be returned to the Alzheimer Society head office in order for the request to be processed. Replacements will be issued at the discretion of the Music Project Coordinator. ü If requesting a music update, I understand that in order for the request to be processed, the music player must be dropped off or mailed to the Alzheimer Society head office. ü Applications may take 4 weeks to process and could take longer depending on program demand. ü For referrals, costs related to shipping will be covered by the Referring Organization or the Alzheimer Society and not the Music Recipient or their family/friends. Primary Contact Name: Signature: Date: o Select if verbal consent received FOR REFERRALS ONLY: Referring Staff Name: Signature: Date: Referring Staff Phone: Referring Staff Email: o Music Recipient is not able to provide consent for themselves and no personal contact is available. By selecting this option and signing above, the Referring Organization assumes full responsibility, accountability, and liability for ________________________________’s participation in the Alzheimer Society Music Project © Alzheimer Society Music Project 2019. Please visit www.musicproject.ca for the most recent version of this form. Music Recipient’s Name: ___________________________________________________________ FAVOURITE ARTISTS OR GENRES: Select or list up to 15 artists that the Music Recipient is a big fan of. If you are unsure of specific preferences, or if the recipient absolutely loves a particular genre, select Mix (maximum of 3). Big Bands/Swing Country & Western Easy Listening—newer Artie Shaw Alabama ABBA Benny Goodman Dolly Parton Barbara Streisand TOP 10 SONGS: Focus on Duke Ellington Garth Brooks Barry Manilow the Music Recipient’s Glenn Miller George Jones Beach Boys all-time favourite songs. Louis Armstrong Hank Williams Bee Gees List song names with artists, Tommy Dorsey John Denver Billy Joel if known. Mix Johnny Cash Carpenters KD Lang Cat Stevens 1. Broadway / Kenny Rogers Céline Dion Show Tunes Loretta Lynn Cher A Chorus Line Merle Haggard Chicago Annie Patsy Cline Dionne Warwick Cabaret Shania Twain Elton John 2. Cats Stompin’ Tom Everly Brothers Fiddler on the Roof Connors Kenny G Guys & Dolls Willie Nelson Olivia Newton-John Grease Mix Tom Jones 3. Hairspray Van Morrison Hello Dolly Crooners Whitney Houston Les Miserables Andy Williams Yanni Mamma Mia Billy Eckstine Mix 4. Miss Saigon Bing Crosby My Fair Lady Dean Martin Easy Listening—older Phantom of the Frank Sinatra Burt Bacharach Opera Jim Reeves Doris Day Oklahoma Johnny Mathis Englebert 5. Sound of Music Nat King Cole Humperdinck The Music Man Perry Como Glen Campbell West Side Story Sammy Davis Jr. Peggy Lee Wizard of Oz Tony Bennett Rosemary Clooney 6. Mix Mix The Four Lads Vera Lynn Classical Eastern Canada & Mix Bach Acadian Beethoven 7. 1755 First Nations / Brahms Anne Murray Indigenous Chopin Great Big Sea Buffy Ste Marie Handel Rankin Family Claude McKenzie Mozart Rita McNeil Florent Vollant 8. Stravinsky Édith Butler Murray Porter Tchaikovsky Mix Susan Aglukark Vivaldi Tanya Tagaq Classical Guitar Opera Troy de Roche 9. Classical Piano Andrea Bocelli Blackfoot Traditional Classical Violin Leontyne Price Cree Traditional Mix Luciano Pavarotti Inuit Katajjaq Maria Callas Iroquois Traditional Placido Domingo Mohawk Hymns 10. The Canadian Tenors Ojibway Traditional Three Tenors Mix Mix ***Turn over for more music selection possibilities*** © Alzheimer Society Music Project 2019. Please visit www.musicproject.ca for the most recent version of this form. Music Recipient’s Name: ___________________________________________________________ Folk Gospel/Hymns/Choir Rock Multicultural & Other Bob Dylan Andrae Crouch AC/DC Genres: We have music from Bruce Cockburn BeBe & Cece Winans Bob Seger many cultures, religions, Buffy Ste Marie Bill & Gloria Gaither Buddy Holly languages, genres, and Donovan Jessye Norman Chuck Berry decades in our library and Gordon Lightfoot Mahalia Jackson Chubby Checker can fulfill most requests. List Ian & Sylvia Tyson Mavis Staples CCR additional artists below (not Jim Croce Harlem Gospel Choir Crosby, Stills exceeding 15 on the entire Joan Baez Mormon Tabernacle Nash & Young form): Joni Mitchell Choir Elvis Presley Judy Collins Vienna Boys Choir Fleetwood Mac __________________________ Leonard Cohen Whitney Houston James Taylor Mama’s & Papa’s Mix Jerry Lee Lewis __________________________ Neil Diamond Neil Young Odetta Reggae/Calypso Pink Floyd __________________________ Peter, Paul & Mary Arrow Queen Pete Seeger Bob Marley Rolling Stones Phil Ochs Calypso Rose Rush __________________________ Simon & Garfunkel Desmond Dekker The Beatles Woody Guthrie Harry Belafonte The Byrds __________________________ Mix Jimmy Cliff The Doors The Eagles Lord Kitchener __________________________ French/Québécois Lord Invader The Kinks Céline Dion Mighty Sparrow The Who Chansons à Peter Tosh Mix __________________________ Répondre Toots & the Maytals Charles Aznavour Mix Soul/R&B __________________________ Édith Piaf Al Green Enrico Macias Aretha Franklin Jazz __________________________ Georges Brassens Instrumental (jazz) Commodores Gilbert Bécaud Charles Mingus Diana Ross Gilles Vigneault Count Basie Fats Domino __________________________ Jacques Brel Herb Alpert Four Tops Jean Leloup Herbie Hancock Isley Brothers __________________________ La Bolduc John Coltrane Jackson 5 La Bottine Souriante Lionel Richie Miles Davis __________________________ Nana Mouskouri Oscar Peterson Luther Vandross Robert Charlebois Pat Metheny Marvin Gaye Roch Voisine Thelonius Monk Otis Redding __________________________ Mix Mix Prince Vocals (jazz) Sam Cooke __________________________ Disco Billie Holiday Smokey Robinson Barry White Stevie Wonder Cab Calloway __________________________ Donna Summer Chet Baker The O’Jays Earth, Wind & Fire Diana Krall The Temptations KC & the Sunshine Ella Fitzgerald Mix Mix (specify additional Band Etta James genres — not exceeding 3 Kool & the Gang Lena Horne Pop / Top 40s on the entire form): Village People Nat King Cole 1930s Mix Mix Nina Simone 1940s Mix Ray Charles 1950s Mix Sara Vaughan 1960s Mix Mix 1970s Mix © Alzheimer Society Music Project 2019. Please visit www.musicproject.ca for the most recent version of this form..