Sign me up for Aquatic Therapy - 2025
WHERE: POTS Pool Englewood, NJ

WHO: Children of All Ages

WHEN: July-August 2025
Morning and Afternoon availability

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

Please fill out one form per child
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Child's Name *
Child's Date of Birth *
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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 Phone Number *
Emergency Contact Relation to Child *
What goals you want to accomplish in Aquatic therapy? *
I give permission for photos of my child to be taken for POTS website/social media:
 *
Polices: 
  • New and returning patients of POTS may require an assessment prior to aquatic therapy.  
  • An adult will accompany my child to sessions and remain throughout the session.
  • 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 will follow the current POTS cancellation policy.
  • I will call POTS at 201-837-9993 to provide my billing information.
Please check to indicate your agreement with our policies:
 *
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