Enrollment - RCEB

Getting Started

[DRAFT] The intake process for infants and toddlers birth to age 36 months begins by calling the Early Start Intake line at (510) 618-6195 or completing the form below.

An RCEB Intake Coordinator will be in touch with you within 24 hours.

Applicant's First Name

Applicant's Last Name

Applicant's Date of Birth

Applicant's Place of Birth

Legal Guardian/Caregiver First Name

Legal Guardian/Caregiver Last Name

Legal Guardian/Caregiver Address

Legal Guardian/Caregiver First Name

Legal Guardian/Caregiver Last Name

Legal Guardian/Caregiver Address

Applicant's Address

Street Address
Address Line 2

City

State/Prov/Region

Postal/Zip

Country

Best Contact Number

What is the best time to reach you?

Email Address

Reason for Referral