Join a Danni Dinocorn Therapy Group

Biographical Information
Consent Form
Payment Information

We are so excited to have you join the Danni Dinocorn family! We know paperwork is a hassle, but please read and complete the following form carefully so we can provide the best service to you.

Name of Child

Last Name of Child

Name of School

Grade of Child

T-Shirt size (to receive a complementary Danni Dinocorn T-shirt)

Date of Birth of Child

Choose a Danni Group to Join

When would you like to attend the sessions?

Name of Parent / Guardian

Last Name of Parent / Guardian

ID number of Parent / Guardian

Relation to Child (e.g. Mother, Father, etc.)

Contact Number of Parent / Guardian

Please provide us with a contact number to which you would like to receive communication in the form of WhatsApp messages. This number will be added to a group/community and will be used to communicate important weekly updates and notifications.

Please let us know if there is anything important you would like us to know aboutyour child, like medication or allergies.

Would you like a proof of payment statement at the end of the 7-weekprogramme to claim back from your medical aid?

Medical Aid Name

Main Member Full Names

Medical Aid Membership Number

Main Member ID number

Consent Form

Please click here to view our consent form.

I hereby declare that I have read, understood and accept the terms and conditions outlined in the consent form.

I consent to my child participating in the Danni Dinocorn Stays Calm group program.

Payment Information

How do you wish to pay?

EFT into Danni Dinocorn Bankaccount (payable before first session)

Cash (payable on the date of first session)

Banking details

Danni Dinocorn PTY LTD
FNB Healthcare Account
Account Number: 631 354 702 83
Branch code: 210835