Muffins & Milestones

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Child's Name

Caregiver's Name

Child's Date of Birth

Contact Number

Lively Therapy Services utilizes social media as a means of promotion and advertising. Though it is not certain, Lively Therapy Services may take photos of you and your child during this event. Please select one of the two options & sign below regarding photos of you and/or your child that may be taken with intent to use for promotional purposes. To ensure proper submission, you MUST select one of the two options below.

I ALLOW Lively Therapy Services, LLC to share photos of myself and my child on social media for promotional purposes. *

Full Name - Digital Signature

I DO NOT ALLOW Lively Therapy Services, LLC to share photos of myself and my child on social media for promotional purposes. *

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