Pediatric Therapy Services | Dynamic Therapy Specialists

Child Therapy Services

We Help Children Reach Their Potential

Pediatric Speech & Language Therapy

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Reading & Writing Intervention

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Auditory
Processing

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Reflex
Integration

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Behavior Management

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Occupational Therapy

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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

Name
First Last
Email
Phone
Address
Street Address Address Line 2 City State ZIP Code
Teletherapy Options*
- Pediatric Speech and Language Therapy
- Auditory Processing Therapy
- Reading and Writing Intervention
- Wow for Focus and Attention
- WOW Yoga for Kids
- Booster Club
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