Admittance Application Form

Admittance Request Form:

  I, (enter full name) the guardian / responsible family of
Mr. / Ms. (enter full name) would like to request
Burlingame Senior Home to include my (enter relation)

Habitat: Private Room Semi Private No Preference

Optional Services:

Cable TV in room private telephone line personal/ particular furniture

Desired time to admit : earliest latest

I would like BSH to guaranty the admittance upon the earliest availability of space. I agree to pay $1,000 non-refundable deposit to the facility, which shall be credited to the first month of rent.  This deposit may be refunded if the residents health conditions worsens in a manner that does not allow BSH to accept the resident any more. In this case the resident's family are responsible to inform the facility immediately.

I do not wish to place a deposit. However, I would like to add my name to the facility's waiting list.

Please fill out this form, print it, and fax it to [650] 348-8690.