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

First Name
Surname
Title—Please choose an option—MrMrsMissMsProfSirLady
Home Telephone No
Mobile Telephone No
Relationship to Child/YP—Please choose an option—MotherStep-motherFatherStep-fatherOther
If Other, please give details
Email
Address
City
Postcode

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

First Name
Surname
If Other, please give details
Date of Birth

Child's/Young Person's Health Information

Liver Condition—Please choose an option—OtherAbernethy MalformationAcute Liver FailureAdenomaAdrenoleukodystrophy - neonatalAegenaes SyndromeAlagille SyndromeAlper's SyndromeAlpha 1 Antitrypsin DeficiencyAscites (primary diagnosis)Autoimmune Liver DiseaseAutosomal Dominant Polycystic Kidney DiseaseAutosomal Recessive Polycystic Kidney DiseaseBile Acid Synthesis DisorderBiliary AtresiaBiliary HypoplasiaBiliary ObstructionBSEP deficiency (formerly PFIC 2)Budd Chiari SyndromeCaroli's DiseaseCD40 Ligand DeficiencyCholangitis (primary diagnosis)Choledochal CystCholesterol Ester Storage DiseaseChronic Liver DiseaseCitrullinaemia Type ICitrullinaemia Type IICongenital Hepatic FibrosisConjugated HyperbilirubinaemiaCrigler Najjar Type 1Crigler-Najjar Type 2Cryptogenic CirrhosisCryptogenic Liver DiseaseCytomegalovirusDrug-induced Liver DiseaseEnlarged LiverExomphalos - NB: Not a liver diseaseFIC1 deficiency (PFIC, BRIC, Byler's Disease)Focal Nodular HyperplasiaGalactosaemiaGallstones (cholelithiasis)GastroschisisGaucher's DiseaseGiant Cell HepatitisGilbert's DiseaseGlis 3 MutationGlycogen Storage DiseaseHaemangiomendotheliomaHepatitis AHepatitis BHepatitis B & DHepatitis CHepatitis EHepatoblastomaHepatocellular CarcinomaHirschsprungs DiseaseInspissated Bile SyndromeIntestinal AtresiaIntrahepatic CholestasisLangerhans Cell HistiocytosisLiver AbscessLiver CancerLiver CystLiver Disease secondary to chemotherapyLiver Disease secondary to Cystic FibrosisLiver LesionsLiver TraumaLiver TumourMCADMDR3 Deficiency (formerly PFIC 3)Mesenchymal HarmatomaMetabolic Liver DiseaseMethymalonic AcidaemiaMicro-Villous Inclusion DiseaseNeonatal HaemochromatosisNeonatal HepatitisNeuroblastomaNiemann Pick Disease Type ANiemann Pick Disease Type BNiemann Pick Disease Type CNo DiagnosisNon alcoholic fatty liver diseaseOrnithine Transcarbamylase (OTC)OxalosisPancreatitisPolycystic Kidney DiseasePolycystic Liver DiseasePorphyriaPortal Hypertension (primary diagnosis)Portal Vein ThrombosisPrimary Intestinal InfangectasiaPrimary non-Hodgkin's Lymphoma of the LiverPrimary Rhabdoid Tumour of the LiverProprionic AcidaemiaReyes SyndromeRhabdomyosarcomaSarcomaSclerosing CholangitisSenior-Loken Syndrome (SLSN)Short Bowel SyndromeTPN Induced Liver DiseaseTrichohepatoenteric SyndromeTyrosinaemia Type 1Unconjugated hyperbilirubinaemiaWilm's TumourWilson's DiseaseWolman's DiseaseZellweger Syndrome
If Other, please give details
Date of Diagnosis
Age when diagnosed
Has your child had a liver transplant?—Please choose an option—YesNo
Date(s) and/or age(s) of Liver Transplant(s)
Main Hospital—Please choose an option—Addenbrooke's HospitalAlder Hey, LiverpoolBirmingham Children's HospitalBooth Hall, ManchesterBorders General Hospital, ScotlandBradford Royal InfirmaryBristol Children's HospitalCharing Cross, LondonCraigavon Area Hospital, PortadownDaisy Hill Hospital, NewryDerriford Hospital, PlymouthDoncaster Royal InfirmaryEastbourne District General HospitalEdinburgh Royal InfirmaryEvelina London Children's HospitalForth Valley Hospital, Larbert (Scotland)Great Ormond Street HospitalGuy's HospitalHeath Hospital, CardiffHull Royal InfirmaryIpswich HospitalJohn Radcliffe, OxfordKing's College Hospital, LondonLeeds General InfirmaryLeicester GeneralLeicester Royal InfirmaryLister Hospital, StevenageManchester Royal InfirmaryMedway Maritime Hospital, GillinghamMiddlesborough GeneralMilton Keynes University HospitalNinewells Hospital, DundeeNorfolk & Norwich HospitalOrmskirk and District Hospital, OrmskirkOur Lady's, DublinPendlebury Hospital ManchesterPeterborough City HospitalPoole HospitalQueen Elizabeth Hospital, BirminghamQueen Elizabeth University Hospital, GlasgowQueen Elizabeth, HackneyQueens Medical Centre, NottinghamRoyal Aberdeen Children's HospitalRoyal Alexandra Children's Hospital, BrightonRoyal Berkshire HospitalRoyal Blackburn HospitalRoyal Children's Hospital, BelfastRoyal Free Hospital, LondonRoyal Liverpool HospitalRoyal Manchester Children's HospitalRoyal United Hospital, BathRoyal Victoria Infirmary (RVI) - NewcastleSheffield Children's HospitalSick Children's Hospital, EdinburghSingleton Hospital, SwanseaSouthampton General HospitalSouthmead Hospital, BristolSt James's University Hospital, LeedsSt Peter's Hospital, ChertseyUniversity College Hospital, LondonWatford GeneralWest Cumberland Hospital, WhitehavenWhittington Hospital, LondonWilliam Harvey Hospital, KentWithington HospitalYorkhill Children's Hospital, Glasgow
Other Hospital(s) (please list)
Other Health Condition(s) and/or Medical Procedure(s) (please list)
Any disabilities? (please list)

Details of other Children/Young People in the Family

How many siblings are there?

Please Give Us Your Consent

To process your child's Health Information—Please choose an option—YesNo

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.

I consent for CLDF's Young People's Team to contact my child—Please choose an option—YesNo
Parent/Carer/Legal Guardian Name
Date

Tell Us How You Want To Hear From Us

Do you wish to receive our information pack(s) via post?—Please choose an option—YesNo

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

CLDF support services and general information and updates, including our Liver Life magazineBy postBy emailBy phone*By text/SMSAll of the above
CLDF Fundraising news & opportunitiesBy postBy emailBy phone*By text/SMSAll of the above

Young Person with a Liver Condition aged 13-15

CLDF support services and general information and updates, including our Liver Life magazineBy postBy emailBy phone*By text/SMSAll of the above
CLDF Fundraising news & opportunitiesBy 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.

Would you like to receive a copy of our Privacy Notice?—Please choose an option—YesNo
How would you like to receive it?—Please choose an option—EmailPost

Any Other Information

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