As CLDF is a UK registered Charity, please only complete this form if you live in the UK.
Home Telephone No
Mobile Telephone No
Social Media UsageInstagramSkypeTwitterFacebookLinkedinYouTubeOther
If other, please give details
Gender---MaleFemalePrefer not to sayOther
If Other, please give details
Date Of Birth
Ethnicity---Asian/Asian British - Any other Asian backgroundAsian/Asian British - BangladeshiAsian/Asian British - ChineseAsian/Asian British - IndianAsian/Asian British - PakistaniBlack/Black British - AfricanBlack/Black British - Any other Black backgroundBlack/Black British - CaribbeanMixed/Mixed British - Any other multiple ethnic backgroundBlack/Black British - CaribbeanMixed/Mixed British - Any other multiple ethnic backgroundMixed/Mixed British - White and AsianMixed/Mixed British - White and Black AfricanMixed/Mixed British - White and Black CaribbeanOther - Any other ethnic groupOther - ArabOther - ChineseWhite - Any other White backgroundWhite - English/Welsh/Scottish/Northern Irish/BritishWhite - Gypsy or Irish TravellerWhite - Irish (Southern)
Liver Condition---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
Have you had a Liver Transplant?---YesNo
Date(s) and/or age(s) of Liver Transplant(s)
Main Hospital---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, PlymouthEastbourne 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)
Any other Health Condition(s) and/or Medical Procedure(s) (please list)
Any disabilities? (please list)
To process your Ethnicity Details---YesNo
To process your Health Information---YesNo
Do you wish to receive our information pack(s) via post?---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.
CLDF support services, family/young people events 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
We have two fantastic residential opportunities - please let us know below if you would like more information.
TALK, TELL, TRANSFORM: would you like a week of fun? TTT is a 5-day digital story-making residential project where you can make new friends and celebrate your uniqueness.YesNo
CLDF WEEKENDER: A 2-night residential. Make new friends, have fun and treat yourself. Participate in exciting activities chosen by you, take part in team games and party the night away!YesNo
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 like to receive a copy of our Privacy Notice?---YesNo
How would you like to receive it?---EmailPost
© 2019 CLDF All rights reserved
Registered Charity Number: 1067331
Registered Company Number: 3431169
Charity Registered in Scotland: SC044387
Telephone: 0121 212 3839
36 Great Charles Street
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