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Publicity Questionnaire

When writing about liver disease in children and the work of the Children's Liver Disease Foundation, journalists like to base their article on a real life story. If you would like to help in raising awareness of childhood liver disease and the work of the Foundation, please let us have the following information.

There is no need to fill in this form if you do not wish any form of publicity.

Family Details

* Name of Child:
d: / m: / y:
* Date of Birth:
* Mothers Name:
* Fathers Name:
Partners Name (if different to mother / father):
* Address:
* Telephone Number (day):
Telephone Number (eve):
Mobile Number:
* Email:


1. When did you first realise that your child was ill?

2. At what age was your child or family member diagnosed as having a liver disease?

3. What were your initial thoughts and feelings when you found out?

4. How has your child's illness affected your family life?

5. How did you hear about CLDF and how do you feel they have helped you and your family?

6. What are some of your proudest and memorable moments for you, your family and your son/daughter?

7. In which type of media would you be willing to participate in order to raise awareness of CLDF and childhood liver disease? Please tick

Local Papers
National Papers
Medical Publications
Consumer Magazines (e.g. Woman, Men's Health, Bella)
Television
Radio

Data Protection Act
The information given to us in this form will only be used in relation to CLDF publicity work.

Please note that all press releases will appear on the CLDF website for approximately 4 weeks.

Please tick here if you do not wish your press release to be placed on the site

Thank you for taking the time to fill in this form.


 
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