Vivian’s Victory is a non-profit organization dedicated to assisting families who experience a poor prenatal diagnosis or have a child with a prolonged illness. Our mission is to provide support, programs and resources to parents of children with a poor prenatal diagnosis or a prolonge illness, not only during their hospital stay but during and after their transition home. We believe no child should fight alone and no parent should choose between their child and “life”. Please complete the following application to request financial assistance for medical and/or non-medical costs related to your child‘s hospital stay/illness. Applications are reviewed as received. You will be contacted once your application has been reviewed. All information will remain confidential. Application Agreement: I hereby apply for assistance to meet medical and/or non-medical expenses due to hardship related to my child’s hospital stay/illness. Vivian’sVictory will determine the amount and type of assistance provided. I vouch for the accuracy and truth of the information provided in this application and authorize Vivian’s Victory to confirm the accuracy of all information contained herein for the processing of this application. I authorize disclosure to Vivian’s Victory of any information relevant to my application as well as any information from other pertinent agencies (including insurance companies). I am aware that falsely submitted information will automatically disqualify my eligibility for assistance from this organization. I understand that Vivian’s Victory assumes no financial responsibility for any medical or non-medical bills submitted for reimbursement. I further authorize my social worker to share any pertinent information with a Vivian’s Victory representative regarding our child’s hospitalization. Parent's Signature*Name of Person Signing* First Last Date* Child's InformationChild's Name*Child's GenderMaleFemaleChild's Date of Birth* Anticipated Date of Discharge* DiagnosisHospitalDoctor/SpecialistMother's InformationMother's Full Name*Mother's Date of Birth* Mother's Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Number of People in Household*Type of Residence*RentOwnMother's Phone*Mother's Email* Current EmployerIf not employed, please list last employer and dates of employment.Mother's Employer Contact and PositionFather's InformationFather's Full NameFather's Date of Birth Does the father have the same address as the mother?*Yes - Same AddressNo - Different AddressFather's Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Father's PhoneFather's Email Father's Current EmployerIf not employed, please list last employer and dates of employment.Father's Employer Contact and PositionAid and AssistanceTotal Amount of Aid RequestedWhy Financial Aid is NeededPlease give a brief description of why financial assistance is needed. Please be specific and include any supporting documents, such as bank statements or billing statements, etc...Aid SourcesWhat are your other sources of receiving assistance, financial or otherwise (social services, friends, family, church, savings, etc...) in the past 12 months?How OftenHow often do you visit your baby at the hospital and what is your means of transportation? How Did you Hear about Vivian's Victory?Additional InformationIf you need additional space, or would like to share more of your story with us, please use the space below.Media Consent ReleaseI hereby give my consent to Vivian’s Victory Non-profit Organization and/or its representatives to use photographs, audio recordings, letters, information and videotape of my child or myself and to use our names, information, these images or recordings in publications, slides, video or on the internet. I understand they will be used to inform and educate families, volunteers, media and the general public about Vivian’s Victory NP and its programs, services and events. I gladly give this authorization to support the efforts of Vivian’s Victory NP. I understand this authorization will remain in effect until written notice is given. ***Signing this Media Consent Release is not a Requirement to Receive Assistance***Media Consent*I give my consentI do not give my consentSocial Worker's InformationThe Social Worker section is not required. If you have a social worker, please have them fill in this section.Social Worker's NameSocial Worker's License #Social Worker's Email Social Worker's PhoneChild's Hospital NameSocial Worker's SignatureI verify the needs of this patient and his/her family during their stay at the hospital.Upload supporting documents.Please upload copies of bills, bank statements, billing statements, etc.. Drop files here or All documents (bill statements, mailers, rental agreements, etc.) needed for fulfillment of application MUST BE SUBMITTED WITH APPLICATION for consideration.