Restricted Grant Application Victorious 4 Teens Programs (V4T)
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Restricted Grant Application
Victorious 4 Teens Programs (V4T)
The mission of Alicia Rose Victorious Foundation (ARVF) is to provide courage and comfort for
hospitalized children by way of providing Teen Lounges, Teen Social Activities and Events, to
enhance the quality of life for adolescents with cancer and other life-threatening illnesses.
Eligibility Requirements:
1. The Hospital must treat adolescents (ages 12 and up) with life-threatening illnesses on an in-
patient basis diagnosed with life-threatening illnesses such as: cancer, Sickle-cell disease, blood
disorders, cardiovascular disorders, cystic fibrosis, cerebral palsy, diabetes, organ failure,
Crohn’s disease and other critical conditions.
2. All sections of the grant application must be completed in full, with attachments (if applicable),
and authorized (signed) by Director of Development or Hospital Administrator ONLY.
Additional information may be required.
3. Financial awards will be in the form of restricted funds which the Grantee must allocate
towards the awarded project/program ONLY. Inappropriate use of the award, shall result in
disqualification for any future funding.
4. The hospital is required to submit a follow-up report detailing the use of the V4T program(s),
as detailed in Section 6.
5. Applications may be forwarded via fax, mail, or as a scanned email document to:
Mail: ARVF; 2465 Voorhees Town Center; Voorhees, NJ 08043
E-mail: info@arvf.org, Attn: Executive Director
Fax: (856)784-1159 Attn: Executive Director
Review Process:
Applications may be submitted throughout the year. You may apply for one, or multiple
programs using the same application. Grants are reviewed and approved on a quarterly basis
by the governing Board of Trustees. Additional information may be required prior to approval.
All decisions regarding awards are made at the sole discretion at the Board of Trustees
meeting. Announcements are made generally within three months of the date of submission.
1SECTION 1
Proposal
(Maximum of 2 pages)
On Hospital letterhead, please include the following information:
1. Brief History: Summarize the Hospital’s experiences with adolescents facing life-
threatening illnesses. List the critical illnesses that are treated and the average length of
stay.
2. Program/Project Description: Describe the details of the program/project you are applying
for. Indicate if this is the first-time, or if there is a history of the program/project.
3. Goals and Objectives: How would the program/project impact the adolescent patient?
4. Target Population: Estimate the number of adolescents this award would serve per year.
SECTION 2
Victorious 4 Teens Program(s)
Financial Award
Date of Submission:
Name of Program(s) you are seeking funding for:
Projected month/year: Start: End:
Hospital Name:
Address:
City, State and Zip Code:
Teen Lounge Program
Funding is available for the specific purpose of creating a new, non-existing Teen Lounge
(TL). A TL is a specific space with a minimum size of 15 x 15 for the significant purpose of
providing a social place for teenagers ages (ages 12 and up) to meet, relax, play games, and
enjoy activities which allow them to escape the rigors of their hospital stay.
Projected Opening Date Teen Lounge:
Teen Lounge Enhancement Program (for existing Teen spaces only)
Funding is available to enhance, renovate or enrich, an existing Teen Lounge. The request
must be consistent with the mission statement of the ARVF.
Total Funding Requested:
2Teen Lounge Activities Program
Funding is available for teen -appropriate social activities and/or events within the Hospital.
Special events may include Arts & Craft activities, Pizza Parties, Movie Nights, Teen Proms,
and other creative in-hospital teen social activities. The request must be consistent with the
mission statement of ARVF.
Name of Program/Project:
Total Funding Requested:
SECTION 3
Victorious 4 Teens Program
In-Kind Award
Date of Submission:
Teen Kit Program
This unique program includes a custom-designed nylon cinch bag filled with teen
appropriate items for entertainment and comfort, as well as a Bandana Throw Pillow made
available to every in-patient child (ages 13 and older), with a life-threatening illness. ARVF
distributes Teen Kits on a quarterly basis on an as-requested basis. Each Teen Kit is valued
at approximately $100.00. This award will commence on the date of the first distribution of
Teen Kits and is valid for one year from that date. To continue receiving teen kits, this
application must be re-submitted each year.
Estimated # of recipients per year:
Please indicate the address for Teen Kit shipments:
Hospital Name:
Attention:
Address:
City, State and Zip Code:
3SECTION 4
Contact Information
For Financial Awards:
Development Officer (or Hospital Administrator):
Name: Title: _______________________
Phone Number: E-Mail: _______________________
For In-Kind Awards:
Manager/Supervisor - Child Life (Responsible for administration of Victorious 4 Teens Program)
Name: Title: _______________________
Phone Number: E-Mail: _______________________
How did you hear about the Alicia Rose Victorious Foundation? (Check One):
Child Life Team: Web-site: Other:
SECTION 5
Attachments
This Section is ONLY required for Financial Awards.
1. For new or existing Teen Lounges, please attach a general floor plan with dimensions of
projected space or existing space, and a photo (if applicable). DO NOT include areas that can
be used by children under the age of 12 years old.
2. Total estimated budget for the Program(s) you are requesting. Please include:
i. List the specific items that you are considering for the program to accomplish your goals
and objectives. (Note: we do not fund construction, labor, or personnel/staffing costs.)
ii. List all other financial resources you currently receive, or may receive specific to this
project/programs, i.e., other foundations, individuals, corporate support, or matching gifts.
(ARVF will consider matching funds received by your own fund-raising initiatives in order to
support any or all of our V4T programs.)
4SECTION 6
Hospital Obligations
The Alicia Rose Victorious Foundation monitors its awards through regular financial and/or
narrative reports submitted by the grantee. This monitoring is designed to ensure that the funds
are used for approved purposes, and to determine whether the award is in accordance with our
mission statement. For financial awards, this application will commence on the date of the award.
Inappropriate use of the award shall result in disqualification for any future funding.
For ALL awards, the Hospital bears the responsibility of the following:
1. Designating a staff member (or members) who will oversee and supervise the V4T
program(s), and make best efforts to monitor its use, in the same manner and to the same
extent any application of the Hospital’s pediatric programs.
2. Upon receipt of any award, the Hospital is to forward a high-resolution digital copy of the
Hospital’s logo.
3. The Hospital hereby releases and holds harmless the ARVF, Corp. and its directors, officers,
employees and affiliates from any and all claims and liabilities arising out of or in
connection with the program described herein, whether any such claim or other liability
arises during the implementation of the funded program or after its completion.
4. Upon initiation or completion of the program(s) granted by ARVF, the Hospital shall make
reasonable efforts to provide ARVF digital photos of patients using the program(s) who
consent to being photographed. (Hospital is to obtain appropriate release and consent
form in accordance with HIPAA regulations).
5. Upon approval of the Hospital, ARVF shall be permitted access to the hospital for the
purpose of photographing and/or filming patients, families, and/or staff who have access
to the V4T programs. The Hospital may make available to its patients and/or parents
liability release forms, in its discretion, to build awareness and solicit ongoing support of
V4T programs which benefit the Hospital directly. ARVF shall be the owner of all rights of
the footage or photography.
For any Financial Award (Teen Lounge, Enhancements, and/or Activities) the hospital bears the
responsibility of the following within six months of receiving award:
1. For Teen Lounges: Placement of a visible plaque in a form acceptable to the hospital, in or
outside of the Teen Lounge signifying ARVF’s contribution. (Upon request, ARVF will
provide appropriate language). The Hospital shall appropriately display ARVF’s Newsletter
and/or brochures for informational purposes only.
2. For Activities/Events: Acknowledgement on brochures, flyers or other collateral materials
used for the specific program award.
3. Submission of a follow-up Financial Report, detailing the expenses incurred for the
completion of the V4T program/project.
4. Invitation to the Opening, Dedication, or Event as well as forwarded copies of any media
coverage the V4T Programs receive including but not limited to: Press Releases,
Hospital/Foundation Newsletters, and Social Media links.
5SECTION 7
Signature
By your signature below, you are authorized to make this commitment on behalf of the
Hospital, and agree to all the criteria set forth in Section 6 of this application.
Authorized Signature:
Print Name:
Title:
Email:
Phone Number:
Office Address:
Date:
EIN #:
Thank you for helping us to Be Victorious!
The Alicia Rose Victorious Foundation (ARVF) is a public charity filed under the 501(c)(3) section of the IRS code, and
registered with the Attorney General of the State of New Jersey.
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