——
Admission Form

Before you fill out this form, please check with our Director of Nursing that our facility has space for you 510-886-2448 Ex 225. If we have an opening and you have been requested to download our admission form, please download and print out the form here.



* Please Do not fill out the forms in your web browser (Internet Explorer, Firefox, Chrome, Safari).


After filling out the form and signing it, there are three ways you may send it back to us:

  • You can scan and email the form to info@fernlodge.org, with subject line "Admission Form"
  • You can mail the form to the following address:

Fern Lodge
18457 Madison Ave,
Castro Valley, CA 94546

  • Or you can fax your form to (510) 886-5992.