Grant Family Testimonial

Thank you for taking the time to complete this form to share a testimonial about your child’s Lyme journey.

Your privacy and that of your child is of significant importance to the LivLyme Foundation. We will not use any personal identifying information as directed by you below.

By completing this form, I hereby authorize the LivLyme Foundation to use my testimonial for marketing and/or promotional materials including but not limited to websites, emails, flyers, posters, advertisements and billboards. I also give permission to the LivLyme Foundation to use creative licensing to edit grammar and/or minor copy before publication use. My name, child’s name, any personal identifying information and/or child’s photo or video will not be used unless otherwise noted. If I choose to have any of our names published, I will indicate below.
*
Checking this box serves as my electronic signature granting permission as stated above.
The information is needed for verification purposes and will not be printed.
Parent Name
First Last
Child Name
First name will not be published unless otherwise noted. Last name will NOT be published.
First Last
Email
Where you can be reached for questions.
Phone
Where you can be reached for questions.
Please provide the following indicating how your name, your child's name and Information will appear when published. .
Parent's Name
- First name
- First name + 1st Initial of last name
- Do not use my name
Child's Name
- First name
- First name + 1st Initial of last name
- Do not use my child's name
State of Residence
State
Choose One
- My state of residence can be used
- Do not use my state of residence
Please Select
Do you have a son or daughter with Lyme Disease? Choose One
Age of Child
Please Type Your Testimonial Here (750 words or less)
Here are some prompts to get you started.
How has the LivLyme Foundation helped your child/family?
How has your child benefited from the use of a LivLyme grant?
What message would you like to share with Olivia?
What words of encouragement can you offer to other families caring for a child with Lyme disease?
OPTIONAL: If you choose to submit a photo or video for review to be used with your testimony, please do so here.
Max. file size: 256 MB.
I hereby authorize the use of the uploaded photo and/or video for use with my testimonial by the LivLyme Foundation for use in marketing and/or promotional materials including but not limited to websites, emails, flyers, posters, advertisements and billboards.*
I agree

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.

Grant Family Testimonial

Thank you for taking the time to complete this form to share a testimonial about your child’s Lyme journey.

The information is needed for verification purposes and will not be printed.

Please provide the following indicating how your name, your child's name and Information will appear when published. .