Apply for Assistance

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.