Little Diamonds Preschool Registration Form (Page 2 of 2) in pdf

Release of Liability and Assumption of Risk

As legal guardian of __________________________________________, I hereby give permission for my child to participate in programs

at Black Diamond Gymnastics LLC. I fully understand that Black Diamond Gymnastics LLC. staff members are not physicians or medi-

cal practitioners of any kind. With that in mind, I hereby release the Black Diamond Gymnastics LLC. staff to render temporary first aid

to my child in the event of any injury or illness, or seek medical help, including transportation by a Black Diamond Gymnastics LLC. staff

member, or its representatives, whether paid or volunteer, to any healthy care facility or hospital, or the calling of an ambulance for said

child should it be deemed necessary. Additionally, I hereby agree to individually provide fro all possible future medical expenses which

may be incurred by my child as a result of any injury sustained while participating at or for Black Diamond Gymnastics LLC.

I recognize that potentially severe injuries can occur in sports or activities involving height or motion, including gymnastics, tumbling, and

trampoline. Being fully aware of these dangers, I voluntarily consent to the aforementioned person(s) participating in any and all pro-

grams at Black Diamond Gymnastics LLC., and I ACCEPT ALL RISKS associated with participation.

In consideration for allowing my child to use these facilities, I, on my own behalf and the behalf of my child and our respective heirs, ad-

ministrators, executors, and successors, hereby covenant not to sue and forever release Black Diamond Gymnastics LLC., its officers, rep-

resentatives, employees, or agents from all liability for any and all damages or injuries suffered by my child while under the instruction,

supervision, or control of Black Diamond Gymnastics LLC., including, without limitation, those damage or injuries resulting from acts of

negligence on the part of its officers, representatives, employees, or agents.

Parents, please make your children aware of the possibility of injury and encourage your children to follow all the safety rules and

the instructor’s instruction.

I have read and understand this MEDICAL AUTHORIZATION, ASSUMPTION OF RISK, AND WAIVER OF LIABILITY and I volun-

tarily affix my name in agreement.

Marketing Release

By signing below, I give permission for Black Diamond Gymnastics LLC. to photograph my child for marketing purposes. I understand

that Black Diamond Gymnastics LLC. will not identify names with images, unless permitted. Initial the line if you do not want your child

photographed.

Payment Information

There is an annual membership fee due at the time of registration. Tuition is due by the first day of each month. Refunds are only granted

for families moving out of Contra Costa County and medical reasons related to the participating student (doctor’s note must be provided).

There is a $20 returned check charge for any checks returned by the bank. I understand that if my check is returned by the bank, Black

Diamond Kids Center will require automatic credit or debit card payments for all future payments. Accounts that become 30 days overdue

will be considered grounds for collections action.

Credit or Debit Card Charge Authorization Agreement

I understand that I must have credit or debit card on file. I understand that I may still pay for services, products, tuition, etc. by cash,

credit/debit or check, however my credit or debit card will be charged the balance of my account if my account is not paid by the first day

of each month. I hereby authorize Black Diamond Gymnastics LLC. dba Black Diamond Kids Center, to charge my credit or debit card

for all services and products related to my family’s enrollment in classes and activities at Black Diamond Kids Center, including but not

limited to tuition, memberships, special events, accessories, etc. (Fees are subject to change.) I understand that it is my responsibility to

inform the Customer Service Office of any changes to my credit or debit card including but not limited to card expiration, name change,

loss or theft of card, etc. In the event my credit or debit card is declined for any reason, I understand I will be responsible for the full pay-

ment as well as any late charges or service charges related. I have read this agreement and understand that I will be held responsible for its

terms and conditions of service.

Drop Class Form

I understand that Black Diamond Kids Center will assume that my child(s) will continue in their class(es) each month until I submit a drop

class form. I understand that I must complete a drop class form and submit it to the Customer Service Office two weeks prior to discontin-

uing classes otherwise I will be responsible for any unattended classes and all account balances (It is not acceptable to turn in the drop

class form to anyone except the customer service office). I understand that I am responsible to pay all account balances. If this form is not

submitted to the Customer Service Office 2 weeks prior to the beginning of a new month of classes, I understand that I am still responsible

to pay, (at the time of submitting this form), all tuition, fees, etc. associated with enrollment in that class(es). A Drop Class Form does not

need to be submitted for class transfers. Simply call or visit the Customer Service Office to transfer classes or programs.

_______________________________________________________________________________________________________________

Print Name of Parent

Parent’s Signature

Date

After School Programs:

Spanish Immersion

Tuition

TOTAL TUITION FOR STUDENT

2pm-4pm

Discount 5% off 2nd and 10% off 3rd sibling

1 Day

$75

Discount 5% off if yearly tuition paid in full

2 Days

$140

Registration Fee: $100

3 Days

$210

Total Due:

5 Days

$275

Little Diamonds Preschool Registration Form Page 2

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