Child Grant Funding Agreement - LivLyme Foundation

BY SIGNING THIS FUNDING AGREEMENT (“Agreement”), the undersigned agree to the terms and conditions set forth below and acknowledge that they have read, understand, and agree to Livlyme Foundation’s (“Livlyme”) Policies and Procedures.

  1. The recipient named below (“Recipient”) has been awarded a one-time grant of $2,500 (“Grant Funds”) solely for the use of medical, drug, and supplement costs directly related to Recipient’s treatment for tick borne diseases (the “Purpose”). I understand that if I do not contact Livlyme within 45 days of receipt of my notice of a Grant Award, the Recipient will forfeit the Grant Funds.
  2. The Grant shall be paid directly to physicians, pharmacies and supplement companies based on the submission of the following information requested by LivLyme: (Provider information, Pharmacy information, Supplement Provider information.) I have read, understand, and agree to the protocols to submit a Medical Request for each doctor’s appointment, treatment, supplement and/or medication as set forth in Section 6 below.
  3. As the Parent/Guardian of the Recipient, I agree that all Grant Funds awarded for the benefit of the Recipient will be used solely by the Grant Recipient.
  4. Unless otherwise approved by Livlyme in writing, all Grant Funds must be spent no later than November 15, 2025.
  5. I further agree that if any portion of the Grant Funds are used for anything other than the Purpose or by anyone other than the Recipient, any remaining Grant Fund will be immediately forfeited, and I may be required to repay the misused Grant Funds to Livlyme.
  6. I understand and agree to adhere to Livlyme’s Payment Policy Process and to submit a Medical Payment Request Form for each medical appointment, treatment, supplement and/or medication for which I am requesting the Grant Funds.
  7. WAIVER AND RELEASE. I, on behalf of the Recipient if under 18, and myself, hereby indemnify, release, hold harmless and forever discharge Livlyme and its officers, directors, employees, agents, successors and assigns, of and from any and all claims, demands, debts, contracts, expenses, causes of action, lawsuits, damages and liabilities, of every kind and nature, whether known or unknown, in law or equity, that I or my child ever had or may have, arising from or in any way related to this Agreement and the receipt of the Funds.
  8. BINDING AGREEMENT. I understand this is a binding agreement that supersedes any other agreements or representations and is intended to provide a comprehensive waiver and release of liability.
  9. Governing Law/Jurisdiction. This Agreement shall be interpreted under and governed by the laws and decisions of the State of Colorado. Each of the parties submits to the exclusive jurisdiction of any state or federal court sitting in Denver, Colorado and its appellate courts in any action or proceeding arising out of or relating to this Agreement or the transactions contemplated hereby.
  10. Counterparts/Electronic Execution. This Agreement may be executed in counterparts and digital copies, each of which shall be deemed an original and all of which shall constitute a single instrument.

I have read and agree to LivLyme’s Grant Fund Payment Policy:

Grant Funds may be used for medical appointments, treatment by doctors/clinics (MD/DO/LLMD/LLND), medications and supplements. Livlyme cannot award grant funds for assistive or adaptive equipment such as in-home HBOT, Rife machines, saunas, biomats, wheelchairs or service dogs. Funds may not be used for medical marijuana. Grant funds will be paid directly to the provider of goods or services. LivLyme can pay for appointments, and can also make arrangements to pay for prescription medication prescribed by your primary care provider and filled by your pharmacy of choice as well as online supplements, if the organization you order from will work with LivLyme. A request form MUST be filled out for each appointment, etc., and it MUST be filled out prior to payment. This is your authorization allowing LivLyme to pay a provider. We will not pay anyone without your authorization. Please allow two weeks for payment to process.

Please direct any questions to:
Denise Erwin, Grants Manager
LivLyme Foundation grantkids@livlymfoundation.org

Grant Recipient(Required)
Recipient Signature (if over 18)
Parent Name(Required)
Parent Signature(Required)
Address

Always shake your Christmas tree outside before you bring it inside.  You never know what critters are still attached to your tree.  Make sure to get a Christmas tree that is not from a “Tick infested” area.