Family Information Form

All information submitted to C.L.A.S.S. is strictly confidential.

To be added to the C.L.A.S.S. Family Information Database, to receive the newsletters and other important information from C.L.A.S.S., please take a moment to fill out the Family Information Form below.

Media Release Form

By signing the Media Release Form, you also give C.L.A.S.S. permission to use your story/picture in fundraising events, newsletters and other forms of print media.

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Please note that all photos, stories, etc. submitted to C.L.A.S.S. remain property of C.L.A.S.S. and will not be returned.

Family Information Form

Use this form to provide information about your child and/or add your name to our Family Information Database. All information is strictly confidential.

* Required

Parent Full Name: *

Name

Relationship to Child: *

Relationship

Mailing Address: *

Address

City: *

City

State: *

State

ZIP Code: *

ZIP

Country: *

Country

Primary Phone: *

Phone

Email Address: *

Website (if any):

Child Full Name: *

Name

Gender: * Male Female

Gender

Diagnosis: *

Diagnosis

Birthday: *

Birthday

Birth Type: Single Birth Multiple Birth

May we include your child's name and age on the C.L.A.S.S website birthday list?

GI Doctor:

Hospital

Surgeries / Procedures

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:

Has been transplanted: OLT LDLT

Transplant Date:

May we include your child's name and anniversary on the C.L.A.S.S website anniversary list?

Other Organ(s):

Transplant Center(s):

Please describe yourself:

Membership Type: New Member Change of Address

Parent Signature: *

Signature

Additional Notes / Information:

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Family Information Form

Media Release Form

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