To Fill Out New Student Registration Info:

If this is your first time joining Zylofone for a program, please fill out as much information as you can on the Registration Form below.  If you have any trouble or have any questions, please don’t hesitate to contact us directly by phone at 845-476-8257 or by email at info@zylofone.org

Work Shop or Program you wish to sign up for

Second Work Shop or Program you wish to sign up for (Optional)

Third Work Shop or Program you wish to sign up for (Optional)

Payment Amounts (You can use the Pay Now button at the top of the page once this form has been completed.)

Payment Options

Students Name (required)

What is the student's disability? (required)

What is the level of involvement of your child/student?
MildModerateSevere

Does your child/student know his or her diagnosis?
YesNo

Does your child have any fine or gross motor limitations? (Please Explain)

Does your child require any special handling for movement difficulties? (Please Explain)

Please tell us about how your child communicates:
VerbalCommunication DevicePicture BoardSigning

Using this communication system, can your child put together 4 or more words independently?
YesNo

Is your child able to listen and follow directions appropriately?
YesNo

How would you describe the degree of difficulty of communicating?

Does your child use an special any special equipment to assist with mobility or other needs?
YesNo

Are there physical, medical, sensory or behavioral concerns that we should be aware of?
Self-stimulatory BehaviorsNon-complianceHitting self or othersTantrumsOthers

Please give us information on the best way to avoid and/or deal with those issues.

Is your child currently on a behavior management plan?
YesNo

What types of reinforcements and/or rewards work best to keep your child motivated?

Please describe your child’s attention span:

Please describe your child’s comprehension and retention skills:

Does your child have any anxieties we should be aware of?

Please let us know anything else you think is important to know about your child. Feel free to send along a copy of your child’s IEP for additional information.

Why would you like your child to participate in this program?

Do you have any concerns about your child participating in the performing arts program that you would like to share with us?

Students Birthdate (required)

Home Street Address (required)

State (required)

Zip Code (required)

School Currently Attending (required)

Grade or Program (required)

Can Student use the restroom on their own? (required)
YesNo

Is your child on a medication or toileting schedule that might conflict with programs schedules? (Please Explain)

Parent or Legal Guardians Full Name (required)

Best Phone Number (required)

Parents Email (required)

By checking this box you agree to the following: LIABILITY WAIVER: I realize that any program, such as ZYLOFONE’s Performing Arts Programs, which involves movement can result in physical injury. I release ZYLOFONE, its owners, instructors and staff from all liability for injury to my child from participation in this program. I permit my child to participate. PROGRAM CHANGES: ZYLOFONE reserves the right to make changes in programs, schedules, instructors, and to cancel classes due to insufficient enrollment. ZYLOFONE also reserves the right to refuse and or cancel the registration of a disruptive student. I understand that Tuition for classes are non-refundable. I have read, understand and agree to ZYLOFONE’s Policies as explained.

By clicking this box you agree to the following: Appearance Release: I hereby give my permission for the person(s) named below to participate in an agency-sponsored event that includes interviews and photographs that may be used for promotional use such as newsletters, other print media and recordings. This participation may also include videotapes and broadcasts. By nature of the photography required, I understand that person’s faces and / or full frontal views may be clearly visible and recognizable. I agree that you may use these photographs and tapes for the above outlined purposes(s). I waive any and all claims or demands which I may have now or in the future regarding production, distribution and use of these photographs / tapes in this project by any authorized agent of Zylofone Studios, Inc.

Today's Date

Any other notes or information we should know?

To pay via Credit Card or Paypal, please use the “Pay Now” button below and select the program in the drop down with the correct amount due. If you have any trouble, please contact us and we can help get your payment processed.

*Delinquent payments will incur a $5.00 surcharge.


Program Payment




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