Summer Therapy Cynergy Kids Bryant

March 1, 2026

Dear Parent(s),

We will be offering continued therapy services for your child during the summer months. In order to schedule services, complete the information below. Please return this form to your child's teacher or fax/mail to our office so we can complete the enrollment process. If you have any questions, please contact our office at 501-943-1681.

Student Name:*

PTOTST

Parent(s) Name:*

Address:*

Phone Number:*

Format: (000) 000-0000.

Alternate Phone Number:

Format: (000) 000-0000.

Email Address:

example@example.com

AM (8-12)PM (12-5)

Special Scheduling Requests:

List any medical concerns/food allergies that we should be aware of:

I DO want my child to receive therapy services during the summer.I will transport my child to summer therapy.I would like Cynergy Rehab Group to transport my child to and from therapy.

I grant Cynergy Rehab Group permission to transport my child to and from summer therapy.

Parent Signature:*

Date:*

Date

We will contact you in April/May to confirm your child's scheduled appointment times.

3417 Marketplace Ave. Ste. 400 Bryant, AR 72022