Application for Housing
This housing application is for IU Health patients (IU Simon Cancer Center / University and Methodist Hospitals) only for our downtown housing locations. It is a good idea to contact your social worker or transplant coordinator for a housing referral since it is required for all downtown applications. Patients and families at Franciscan Health should contact their social worker for a southside housing application. For information about housing for patients at other hospitals, email info@fairhavenfoundation.org.
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Have you been served at Fair Haven before?
Please select a response
No
Yes
Please complete our return guest form using the button below.
Return Guest Application
Please continue with this application.
Application For:
Overnight Lodging
Minimum number of separate beds requested: (subject to availability)
Please select a response
1
2
3
Shower and Laundry Only
If you selected Overnight Lodging, please complete the Start and End Dates below.
Estimated Start Date of Overnight Lodging
Estimated End Date of Overnight Lodging
If you selected Shower and Laundry Only, please complete the Date and Time below.
Requested Date
Requested Time
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Patient Name ( First and Last )
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Country
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USA
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Address
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Diagnosis
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Treatment
Allogeneic Bone Marrow/Cord/Stem Cell Transplant-CA
Autologous Stem Cell Transplant-CA
Burn Unit
CAR T-Cell Therapy
Cardiovascular Critical Care
Chemotherapy-CA
Clinical/Drug Trial
COLTT
Critical Care/ICU
Emergency Medicine (Injury/Trauma/Accident)
Evaluation
Heart Transplant
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Kidney Transplant
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Lung Transplant
Multivisceral Transplant
Neurology
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Other Organ Transplant
Palliative Care
Pancreas Transplant
Photopheresis
Population Health
Radiation and Chemotherapy-CA
Radiation-CA
Rehabilitation
Sleep Lab
Stem Cell Collection
Surgery
Ventricular Assistive Device
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Patient Date of Birth (MM/DD/YYYY)
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Patient is being treated at:
IU Simon Cancer Center
IU Health Methodist Hospital
IU Health University Hospital
Riley Children's Hospital
Ascension
Central Indiana Cancer Center- IUH
Community
Eskenazi
Franciscan
IU Health North /Schwarz Cancer Center
IU Health Physicians
IU Health West
IU Health- Carmel
Long Term Care
Other
Will the patient be inpatient or outpatient?
Inpatient - Hospitalized  
Outpatient - Non-Hospitalized  
Both, during this stay.
Assigned Social Worker / Hospital Staff or Physician
Please select a response
None
Unknown
Haley Adams
Kim Anderson
Shawn Appleget
Amanda Avant
Jennifer Baatz
Jill Bailey
Kimberley Baker
Clare Barnett
Jay Baute
Pam Baute
Tracy Beer
Amy Bender
Jenny Bennett
Karen Bettner
Robyn Bland
Tammy Bolen
Kali Bonanni
Chantelle Bose
Allyson Bradford
Mitchell Brauchla
Meredith Brooks
Meredith Brooks
Katie Butler
Amanda Callis
Lindsey Campbell
Beth Canfield
Kate Carlson
Haley Carver
Clint Cary, MD
Carly Case
Araceli Castillo
Donna Church
Rhonda Clair
Aaron Cohen
Laura Coordinator
Raven Cotham
Nan Cotton
Sarah Courtney
Macie Cox
Leah Crane
Cheryl Cutshall
Debbie Decker
Courtney Dilts
Kate Dobson
Monica Dycus
Joy Dyer
Elyse Eagleson
Emily Ebelhar
Ashlyn Edwards
Jamie Elliott
Kyra Elliott
Debbie Evans
Michael Ferguson
Stephanie Fish
Karen Fitzgerald
Nancy Flamme
Jane Forbes
Cammie French
Johannah Frey
Lindsey Frissell
Carol Gaffney
Megan Gelarden
Melissa Gilliland
Danyel Gooch
Christi Gorth
Kay Guidry-Jones
James Haggie
Sarah Hale
Carrie Haney
Olivia Hansen
Monica Hanza
Lauren Harger
Andy Harner
Natalie Harrigan
Angie Harrison
Stephanie Hayden
Bri Heffernan
Shawn Hensley
Jessica Hesch
Jessica Hesch
Mary Hindman
Tia Hinkle
Surgeon- House
Deia Howell
Janet Hoyer
Jaimie Huguenard
De Jinerson
Tiera Johnson
Shari Jones
Abby Joyner
Claire Kammen
Kathy Kane
Dr. Koch
Jessie Laeder
Erika Leak
Sara Lengerich
Caroline Lipp
Dori Lipschultz
Alex Long
Dinah Love
Angi Lynch
Mary Lynn
LeeAnn Mailly
Erika Marks
Carmen Marte
Timothy Masterson, MD
Karen Matthews
Taylor Mattingly
Laurenn Maurice
Lesley May
Jessica Mayo-Schwab
Kari McCarty
Michelle McClory
Anne McCord
Sophia McCormick
Sylvia McGuire
Cheri McKinney
Sade MD
Judith Miles
Jennifer Miller
Trysha Miller
Amanda Milner
Norm Minor
Diane Monceski
Katelyn Murphy
Aubrea Mvalo
Dolly Neihaus
Kate Nickelson
Delores Niehaus
Jenna Nielsen
Alexandra Noble
Natalie Nusinow
Robin O'Bryant
Liz Patrick
Amber Peck
Jenny Ramos
Jenny Ramos-Smith
Kayla Reddington
Diana Reed
Melissa Renbarger
Brittany Reynolds
Carrie Riessen
Kelly RN
Amy Ross
Tracey Rush
Kim Rusununguko
Cassandra Schroeder
Cassie Schroeder
Dr. Jennifer Schwartz
Kristin Seneriz
Sarah Sexson
Stephanie Shook
Caitlyn Silger
Sarah Smillie
Deb Smith
Rhonda Smith
Sydney Sparks
Alexandra Spicer
Tina Stachmus
Lia Stallworth
Bizz Steele
Cathleen Steele
Alyssa Steinman
Paige Stratton
Karen Stricker
Donna Stroude
Cheryl Sullivan
Josh Sumner
Maggie Sutterfield
Michelle Sutterfield
Hollyn Swider
Tara Tanner
Ashtyn Taylor
Heidi Taylor
Elizabeth Terry
Jill Thomas-Kingery
Sarah Thomason
Lynette Thompson
Hannah Todd
Teresa Tuholski
Carolyn Turpin
Isaiah Tworek
Beth Webb
Kandyce Webster
Wendy Wectawski
Samantha Wentz
Christopher Westra
Christine Willard
Nikki Willhelm
Maya Williams
Mya Williams
Savanna Williamson
Lisa Wood
Beth Zaberdac
Other
Please complete the following section. If there will not be a caregiver, please use the patient's information.
You may skip the address section below.
Please complete address information below.
Caregiver's Name
Date of Birth (MM/DD/YYYY)
Relationship to patient
Patient
Mother
Father
Son
Grandparent
Other family member
Other
Significant other
Spouse
Friend
Parent
Sibling
In-Law
Unknown
Stepparent
Cousin
Grandchild
Daughter
Ex-Spouse
Aunt
Uncle
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Country
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Argentina
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Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
British Virgin Islands
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos [Keeling] Islands
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Comoros
Congo
Cook Islands
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Croatia
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Djibouti
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El Salvador
Equatorial Guinea
Eritrea
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Falkland Islands
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French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong
Hungary
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India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Ivory Coast
Jamaica
Japan
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Jordan
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Kosovo
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Laos
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Lithuania
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Mali
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Mauritius
Mayotte
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Myanmar [Burma]
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Nauru
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New Caledonia
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Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
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Palestine
Panama
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Peru
Philippines
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Poland
Portugal
Puerto Rico
Qatar
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Sri Lanka
Sudan
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Tanzania
Thailand
Togo
Tokelau
Tonga
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Tunisia
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U.S. Minor Outlying Islands
U.S. Virgin Islands
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Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Wallis and Futuna
Western Sahara
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Other
Address
City/Villa/Town
County/District
State/Province
State/Province
--Select--
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
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OR
PA
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SD
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UT
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VT
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Zip
Additional Guests / Family Members
Add Another Guest
Caregiver's Email
Patient Phone
I agree to receive texts at this number.
Caregiver's Phone
I agree to receive texts at this number.
Emergency / Additional Phone
Emergency / Additional Contact name
Does anyone who will be staying at one of our facilities smoke? (This will not affect the status of your application.)
Yes
No
Is vehicle parking needed?
Yes
No
Comments / Additional Needs
*
By checking this box, I grant permission for health care professionals to release information including my name, my family’s and caregiver’s names, and medical information to Fair Haven staff and volunteers for the purpose of applying for housing and/or other assistance. I authorize Fair Haven and/or Core Redevelopment, LLC to perform a criminal background check(s) on all guests applying for housing.
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By checking this box, all guests agree to NO SMOKING, NO PETS, NO ILLEGAL SUBSTANCES in any of our facilities at any time. I understand that if I fail to comply with these rules I may be required to vacate the premises. If provided with housing, I grant Fair Haven permission to use information about me and my family for the purpose of supporting this cause as a nonprofit organization.
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