Sign me up for Adaptive Swim Lessons 2025
WHERE: POTS Pool Englewood, NJ

WHO: Children of All Ages

WHEN: Morning and Afternoon availability

FEES: Package of 4 lessons for $340.00

Individual lessons: $95 each

For more info, e-mail us at office@potsot.com or call 201-837-9993

Please fill out one form per child.
Sign in to Google to save your progress. Learn more
Child's Name *
Child's Date of Birth *
MM
/
DD
/
YYYY
What grade is your child going into? *
Is your child currently receiving OT, PT or Speech Therapy at POTS? *
Parent's Name *
Parent's Cellphone *
Parent Email *
Emergency contact name *
Emergency Contact Relation to Child *
Emergency Contact Phone Number   *
What goals you want to accomplish in Adaptive Swimming? *
I give permission for photos of my child to be taken for POTS website/social media
 *
Policies:
  • A package of 4 adaptive swimming lessons is $340. The fee for Individual 30 minute lessons is $95 each.
  • A non-refundable deposit of $95.00 per swim package is due upon registration to secure my child's spot.
  • An adult will accompany my child to sessions and remain throughout the session.
  • There  are no makeups for missed sessions.
  • Insurance does not reimburse for adaptive swim sessions and POTS does not provide a super bill.
  • I understand that if the weather looks questionable, I will be in contact with POTS prior to the session.
  • Sessions canceled less than 24 hours in advance must be paid in full.
  • I will call POTS at 201-837-9993 to provide my billing information.
Please check to indicate your agreement with our policies
 *
Required
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Pediatric Occupational Therapy Services.

Does this form look suspicious? Report

Google Forms