February 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:
*
School Child Attends:
*
Therapy Services: (please check all that apply)
*
PT
OT
ST
Student(s) Name:
*
Parent(s) Name:
*
Address:
*
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 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.
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