As CLDF is a UK registered Charity, please only complete this form if you live in the UK.

    Name & Details of Parent/Carer/Legal Guardian


















    Name of Child or Young Person with a Liver Condition (aged 0-24)








    Child's/Young Person's Health Information










    Details of other Children/Young People in the Family






    YesNo




    YesNo




    YesNo




    YesNo




    YesNo

    Please Give Us Your Consent


    To be completed by Parent/Carer/Legal Guardian of Young Person with a Liver Condition aged 13-15
    For any young person aged 13-15 we also request that you give us your consent for CLDF's Young People's Team to contact your child and for them to receive our information.



    Tell Us How You Want To Hear From Us

    Children's Liver Disease Foundation (CLDF) would love to keep in touch with you about our vital work. By contacting you in the way you choose, we can be more cost effective in our communications and marketing activity. Please let us know what you would like to hear from us about and how by ticking the box(es) below. You can choose all these options or just one or two of them-it's up to you.
    *Please note you will only ever be contacted by phone by a member of the CLDF team.

    Parent/Carer/Legal Guardian

    By postBy emailBy phone*By text/SMSAll of the above
    By postBy emailBy phone*By text/SMSAll of the above

    Young Person with a Liver Condition aged 13-15

    By postBy emailBy phone*By text/SMSAll of the above
    By postBy emailBy phone*By text/SMSAll of the above

    Your Details Are Safe Wth Us

    We'll always store your personal details securely. We'll use them to provide the service(s) that you have requested and communicate with you in the way(s) you have agreed to. Your details may also be used for analysis purposes, to help us provide the best possible service. We won't sell your details to anyone else and we'll only share them with suppliers working on our behalf, or if required to do so by law. For full details please CLICK HERE to view CLDF's Privacy Notice. We suggest that you read this Privacy Notice to understand what information we hold, how we use it and what your rights are.


    Any Other Information