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CBS Permission English - Cornel Bekker Self Development Center
72 Premier Street, c/o Premier and Third Street, Krugersdorp-North.
Cell: Annalien: 084 054 3786 Minette: 082 415 3071
Client Details:
Please fill out the details of the person who will attend the program.
(* fields are required)
Name & surname:
*
Known as: (nickname)
*
Date of birth:
*
Date Format: MM slash DD slash YYYY
Age:
*
Referred by:
*
Available Programmes:
*
I hereby give permission for participation in the following programme/s:
Anxiety management (For Children) - 1 Session @ R100 x 4 sessions = R400
Anger management (For Children) - 1 Session @ R100 x 4 sessions = R400
Bullying (For Children) - 1 Session @ R100 x 4 sessions = R400
Divorce guidance (For Children) - 1 Session @ R100 x 4 sessions = R400
Development of my selfimage (For Children) - 1 Session @ R100 x 4 sessions = R400
Parental guidance (For Parents) - 6 Sessions @ R900 Single Parent
Parental guidance (For Parents) - 6 Sessions @ R900 Both Parents
General Information
Payable before sessions begin.
M JvRensburg,
ABSA Savings Account: 318 1914 92
Branch Code: 632005
Reference: CBS + Name & Surname of the Child
Please email the proof of payment with this form to: Annalien -
filteg@telkomsa.net
You will not be able to claim these services from your medical aid.
Although the staff at the centre do everything within their power to ensure the safety of your child, we accept no liability or responsibility for any injuries, damage or loss in or outside the house or jungle gym. We are also not responsible for your child when he leaves the premises. Please ensure that you collect him/her on time .
A certificate of attendance will be issued. No reports will be written.
The programmes for children are run on Wednesday afternoons from 15:30 to 16:30.
The parental guidance programmes run on Wednesday evenings from 19:00 to 20:30.
Name & Surname of Father:
*
Cell Phone Number of Father:
*
Name & Surname of Mother:
*
Cell Phone Number of Mother:
*
Name & Surname of Client/Child:
*
Cell Phone Number of Client/Child:
*
Permission to place name & picture on FB or our website?
*
Yes
No
