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.

* Application For:
Overnight Lodging
Shower and Laundry Only
If you selected Overnight Lodging, please complete the Start and End Dates below.


If you selected Shower and Laundry Only, please complete the Date and Time below.
Requested Date
Requested Time
*
Yes   No

*
U.S. / Canadian Postal Code lookup


*
*
Inpatient - Hospitalized   Outpatient - Non-Hospitalized   Both, during this stay.

*
Please check box below if caregiver lives at same address as patient.
U.S. / Canadian Postal Code lookup


Additional Guests / Family Members

Add Another Guest
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
* 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 to perform a criminal background check(s) on all guests applying for housing.
* 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.