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A member of our team will review your submission and contact you within 24 hours.

If you’d like to see whether we can help your child sooner, feel free to give us a call at 225-767-5032.

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Wow Yoga Registration Form

STUDENT INFORMATION
Name*
First MI Last
Home Address*
Street Address Address Line 2 City State ZIP Code
Class Location*
Specify Classroom Child Is In*
Home Phone
Cell Phone
Email*
For Confirmation / Reminder
CONTACT INFORMATION
Parent / Guardian Name*
First Last
Home Phone
Work / Cell Phone
Emergency Contact Name
Relationship to Student
Emergency Phone
Alternate Phone
Do you give permission for Dynamic Therapy Specialists, LLC. to use pictures taken of your child during yoga for Marketing purposes?*
- Yes
- No
To pay by CHECK:
Amount
Check #
To pay by Paypal: email address you'd like invoice sent to

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Teletherapy Options - Registration Form

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