1003 Carol Lane
Lafayette, CA 94549
(925) 283-6792

License # 073406651


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All of the required forms for admission will be provided during your admission appointment.  We find it easier if you fill out the Admission Application in advance and bring it with you. 

Admission Application

Thank you!


Required Forms for Admission:
- Application for Admission
- Admission Agreement with Authorized Signatures (form provided at your admission appointment)

- Identification and Emergency Information (LIC700)
- Signed and dated receipt of Notification of Parents Rights (LIC995)
- Personal Rights – Child Care Facilities (LIC613A), receipts signed and dated.
- Child’s Preadmission Health History – Parent’s Report (LIC702)

AND ALL 3 Forms Shown Below:
- Child’s Preadmission Health Evaluation – Physician’s Report (LIC701)
- California School Immunization Records (“blue cards”, PM286) for non-school-age children.
- Consent for Medical Treatment (LIC627)

OR
- Written statement from parents or authorized representative exempting child from medical assessment, immunizations, and treatment because of adherence to a religious faith that practices healing by prayer or other spiritual means; or physician’s statement that immunization is not indicated.