Certification Program Application1 Program Information2 Personal Information3 Musical Background4 Experience & Training5 Your Goals6 Work BackgroundProgram InfoThis application is for admission to the following season*SeasonFall 2019Winter 2020Spring 2020Summer 2020Fall 2020If you know at this time which hospital you would like to play all or a portion of your internship hours, please select:RWJUH HamiltonRWJUH RahwayValley HospitalOtherPlease specify: Personal InfoLegal Name* First Middle Last Name You Would Like To Be CalledAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Phone*Email* Best way to contact you if there is a cancellation:Phone callText MessageEmail Musical BackgroundIf you have no musical background, please skip to question #4 at the bottom.1. Do you read music? Which clef(s)?2. What musical instruments do/did you play and what is/was your level of proficiency on each?Please indicate the nature of your musical training and experience.Please select all that apply: Do you improvise? Do you play by ear? Do you write your own arrangements? Do you write your own music? Do you currently take harp lessons? Do you teach music? Do you perform?With whom have you studied / are you currently studying?4. Do you sing? What genres (pop, oldies, hymns, Broadway, etc.) are your favorites?5. What is your favorite kind of music to listen to? Experience & TrainingDo you presently own a therapy harp? If so, what kind?Do you own any other instruments that you'd like to use for therapeutic purposes?Have you already had experience playing music at the bedside of the ailing?In front of a group?In a public area in a health-care facility?Where and for how long?Do you have any medical, healthcare, hospice or spiritual care experience? If so, please describe.Do you have any training and/or credentials in any alternative or integrative health care? If so, please describe.Do you have a regular practice/ritual for stress relief?Have you recently experienced a loss? Please describe.Do you have any credentials from other healing and/or sound healing institutions? If so, please describe. Your GoalsWhat do you see as your main goal after you achieve a Bedside Harp certification?What audience of people and/or what kind of medical facility do you think you would like to work with?What kind of audience of people and/or what kind of medical facility do you think it would be difficult for you to work with?What strength of yours do you believe you will be able to draw upon in the work?What would you consider to be an area or areas you believe you’ll need to work on as you prepare to do this work? Education/Work ExperienceEducation: Please include high school, vocational school, college, graduate school.Work: Please summarize your professional/work experience:Where did you first hear of our program?Please mark all that apply: Word of Mouth Mailing Internet Facebook LinkedIn Instagram Harp Therapy Journal Somerset Harp Festival Referral OtherIf other, please specify:Additional CommentsAdditional CommentsTuition for Modules I and V (internship), and materials fee will be made directly to Bedside Harp. Please complete this application, along with an informal recording of yourself playing ten tunes, very simply, on the harp, to the address Bedside Harp 4802 Neshaminy Blvd. Suites 3-4 Bensalem, PA 19020, or e-mail them as attachments to email@example.com and firstname.lastname@example.org. Tuition for Modules I (classroom) and V (internship) and materials fee will be due upon your formal acceptance into the program. There are two payment plans: (1) Pay for all classroom modules and materials 30 days prior to the start of Module I and receive a 5% discount. (2) Pay as you go: You would pay for the module and that modules materials fee ($60.00 per module)10 days before the start of that module. Bedside Harp regrets that we are unable to offer refunds within fourteen days of the start date of our modules.PhoneThis field is for validation purposes and should be left unchanged.