Use this form to provide information about your child and/or add your
name to our Family Information Database. All information is strictly
confidential.
Parent/Guardian Information
*Required fields
First & Last Name:*
Relationship to Child:*
Street Address:*
City:*
State:*
Zip Code:*
Country:*
Home Phone:
Email:*
Web Address:
Child with Liver
Disease/Disorder/Transplant
First & Last Name:*
Gender:
Girl
Boy
Diagnosis:*
Birthday (M/D/Y):*
Single
Birth
Multiple
Birth
May we include your child's name
and age on the C.L.A.S.S. Newsletter Birthday List?
Yes
GI Doctor/Hospital Information
GI Doctor:
Hospital:
Surgeries/Procedures:
Liver Transplant Information
My child has stable
liver disease and does not need a transplant at this time.
My child is
on the UNOS transplant waiting list.
PELD Score:
Date Listed (M/Y):
My child has been
transplanted:
OLT
LDLT
TX Date(s) (M/Y):
May we include your child's name
and anniversary on the C.L.A.S.S. Newsletter Anniversary List?
Yes
Other Organ(s):
Transplant Center(s):
Please Describe Yourself:
Parent
of pediatric liver patient
Liver
Patient (yourself)
Other
family member
Health
care professional
Social Worker
Other
New
Member
Change of Address
By signing below, I give my
permission for the Children's Liver Association for Support
services (C.L.A.S.S.) to release my name and/or contact information
for the purposes specified above. I understand my name will
not be released for any other purpose and that the information
contained in this form is strictly confidential.
Parent Signature:*
Additional Notes/Information:
Children’s Liver Association
for Support Services
27023 McBean Parkway #126
Valencia, CA 91355
Toll-free: 1-877-679-8256
Local phone/fax: (661) 263-9099 Terms of UseContact Us
Parent/Guardian Information
*Required fields
GI Doctor/Hospital Information
Liver Transplant Information
Please Describe Yourself: