2026 Summer Therapy Letter with Transportation

CYNERGY
REHAB GROUP
PHYSICAL•OCCUPATIONAL•SPEECH
March 1, 2026
Dear Parent(s),
Thank you for allowing us to serve your child during the 2025-2026 school year. 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 870-333-5198.
Student Name:*
PTOTST
School Child Attends:*
Parent(s) Name:*
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:*
Format: (000) 000-0000.
Alternate Phone Number:
Format: (000) 000-0000.
Email Address:
example@example.com
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:*

Clear
Date:*

MonthDayYear
Date
AM (8-12)PM (12-5)
Special Scheduling Requests:
List any medical concerns/food allergies that we should be aware of:
I DO NOT want my child to receive therapy services during the summer.
We will contact you in April/May to confirm your child's scheduled appointment times.