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Application for Admission

Please fill out the form below to submit an Application for Admission.
If you prefer, you may also download and fill out our Application for Admission and fax it to 815-877-2040. Thank you!


    Christian Retirement Center

    3470 N Alpine Rd
    Rockford, IL 61114

    I declare that the information on this application is complete and accurate. I also agree with the Criteria for self care found in the Health History and Information section of this form which will become part of my permanent record

    This information will be reviewed by the admittance committee and you will be advised of its acceptance. If you go on our waiting list, health and financial information may need to be updated when we have suitable accommodations and you are ready to move in.

    • MaleFemale

    Family & Personal History

    Marital Status
    • SingleMarriedWidowedDivorced
    Closest relatives or friends concerned with your well being

    Church & Spiritual Relationships

    Fairhaven Christian Retirement Center is an affiliate of the Great Lakes District of the Evangelical Free Church of America Would you be able to be comfortable in this Christian environment?

    Social Interests

    Names of current residents you know or personal non-family references

    Health History

    Primary Physician

    Criteria for Self Care (may include help of a spouse)

    1) You must be able to self ambulate in your room.
    2) You must be able to dress and undress.
    3) You must be able to use the restroom without assistance.
    4) You must be in a physical or mental state to live alone, with the potential occasional custodial care.
    5) You must be able to live in a communal setting without conflict with other residents or staff.
    6) You must be able to perform normal activities of daily living (ADLs)
    7) You must be able to maneuver to the dining room and to locate your room without assistance.

    Fairhaven has the right to transfer a resident to a higher level of care if any of these criteria is not met.
    Your power of attorney for health care is:

    Financial Statement Value of Current Assets

    Monthly Income

    Long Term Care Insurance

    Payment Of Monthly Fees

    Your power of attorney for Finance is:

    *All information will be kept confidential and not compromised in any way.

    In Case Of Emergency Notify

    Personal Health Insurance(Copy of information for file)

    End Of Life Arrangements