JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Sign me up for Aquatic Therapy
For details and fees check us out all of our summer programs at
https://www.potsot.com/summer-programs
Please fill out one form per child
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Parent's Name
*
Your answer
Parent's Cellphone
*
Your answer
Emergency contact
*
Your answer
Child's Name
*
Your answer
Child's Date of Birth
*
MM
/
DD
/
YYYY
What grade is your child going into?
*
Your answer
Is your child currently receiving services at POTS
*
Yes
No
What goals you want to accomplish in Aqua therapy this summer
*
Your answer
Please check to indicate your agreement with our policies
*
A non-refundable deposit of $100.00 is due upon registration to hold your spot
Aqua therapy sessions are scheduled once or twice a week in a recurring spot
I understand that if the weather looks questionable, I will be in contact with POTS prior to the session.
Sessions that are rained out will take place indoors at POTS in Teaneck unless other arrangements are agreed upon in advance
An adult will accompany my child to sessions and remain throughout the session
Session canceled less than 24 hours in advance will be paid in full
I will email
info@potsot.com
or call 201-837-9993 to provide my billing Information
I have read and accepted the above terms
Required
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms