Fairhaven

Christian Retirement Center

3470 N Alpine Rd
Rockford, IL 61114
815-877-1441
https://www.fairhaven.cc

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

Name (printed)

DATE

Signature

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.

LAST NAME

FIRST NAME

MI
ADDRESS

CITY
STATE

ZIP

Phone

Cell
Email
Date Of Birth

Age

MaleFemale

Family & Personal History

Place of Birth
Parent's names

Mother's Maiden Name

Marital Status

SingleMarriedWidowedDivorced
Spouse's name

Anniversary Date
Number of Siblings

Children

Grand Children

Great Grandchildren

Closest relatives or friends concerned with your well being

Name

Relationship
Phone

Address
Cell Phone

Name

Relationship
Phone

Address
Cell Phone

Name

Relationship
Phone

Address
Cell Phone

Education and training

Previous occupation

Employer

Military service

Branch

Church & Spiritual Relationships

Church

Pastor
Address

Phone
Years of membership
Services performed for your church

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?

Comments

Social Interests

Where have you traveled
Names of clubs and organizations you are or have been affiliated with
Hobbles and Interests

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

Name

Relationship
Phone

Address
Cell Phone

Name

Relationship
Phone

Address
Cell Phone

Name

Relationship
Phone

Address
Cell Phone

Health History

List your medical limitations
Please explain needs for special attention by nursing staff
List of medications (use extra page if necessary)
List serious illnesses, hospitalizations or operations in the last five years

Primary Physician

Name

Phone
Address

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:

Name

Relationship

Address

Phone

Financial Statement Value of Current Assets

Real Estate Holdings $

Loan or Debt $
Stocks and bonds $

Checking account(s) $
Savings account (s) $

Other $
(Please Explain)
Total Assets (less loans)

Monthly Income

Social Security $

Pensions / profit sharing $
Interest & dividends $

Annuities $
Other $
(Please Explain)
Total Income / month $

Long Term Care Insurance

Company

Policy #
Define coverage

Payment Of Monthly Fees

To whom should the Fairhaven monthly bill be sent?

Your power of attorney for Finance is:

Name

Relationship
Address

Phone
Cell Phone

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

Social Security Number (copy of card for file)

Medicare Number (copy of card for file)

Race

In Case Of Emergency Notify

Name

Relationship
Address

Phone
Cell Phone

Name

Relationship
Address

Phone
Cell Phone

Name

Relationship
Address

Phone
Cell Phone

Personal Health Insurance(Copy of information for file)

Company

Address
Group #

Policy #

End Of Life Arrangements

Mortician

Phone
Address
Cemetery

Phone
Address

Resident Application