Little Diamonds Preschool Registration Form
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2OFFICE USE ONLY
Little Diamonds Preschool
Email
___
Fees Posted and Collected
___
Registration Form 2015-2016
Registration Fee
___
073405691
lic. #
File Folder Created
___
Payment Policies Explained ___
Today’s Date: ________________
□ New □ Returning □ Currently Enrolled In Other BD Program
Student’s Name: ________________________________________________________________________________________
Last
First
Middle
Prefered
Date of Birth: _____/_____/_____
Age: ______
Gender (circle): Male
Female
Address: _____________________________________________ City: ___________________________ Zip: _____________
Home Phone: (
)__________________________ Email: ________________________________________________
Mother’s Name: _____________________________________ Cell Phone: (
)________________________________
Occupation: _______________________________________________
Living with student: Yes _____ No _____
Deceased: Yes _____ No _____
Divorced: Yes _____ No _____
Employer: ________________________________________________
Work Phone: (
)_________________________________________
Father’ Name: ______________________________________ Cell Phone: (
)________________________________
Living with student: Yes _____ No _____
Occupation: _______________________________________________
Deceased: Yes _____ No _____
Divorced: Yes _____ No _____
Employer: ________________________________________________
Work Phone: (
)_________________________________________
1. Emergency Contact: ______________________________ Relationship: __________________ Phone: _______________
Medical Information
Student’s Physician: _________________________________ Physican’s Phone: (
)_______________________________
Insurance Carrier: ___________________________________ Policy______________________________________________
Please list all medical concerns, allergies, or information we should know about your child: _______________________
______________________________________________________________________________________________________
Monthly Tuition
6:30am-6:00pm
Tuition
9:00am-12:00pm
Tuition
9:00am-4:00pm
Tuition
Tuesday/Thursday
$495
Tuesday/Thursday
$460
Tuesday/Thursday
$350
Monday/Wed/Friday
$565
Monday/Wed/Friday
$540
Monday/Wed/Friday
$440
Monday-Friday
$775
Monday-Friday
$635
Monday-Friday
$550
Extended Care if available $8 per hour
Black Diamond Gymnastics LLC.
*9:00-4:00 and 6:30-6:00 includes
2015 Elkins Way Suite D
Spanish Immersion
Brentwood, CA 94513
Phone: (925) 516-6619 Fax: (925) 516-0466
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