Contact (parent or carer) First Name*:
Contact Surname*:
Participant or Child's Name*:
Participant or Child's Date of Birth*:
Sex of Child*:
Which of the following best describes your child's ethnicity?	-- Please select an option -- Indian Pakistani Bangladeshi Chinese Any other Asian background Caribbean African Any other Black, Black British, or Caribbean background White and Black Caribbean White and Black African White and Asian Any other Mixed or multiple ethnic background English, Welsh, Scottish, Northern Irish or British Irish Gypsy or Irish Traveller Roma Any other White background Arab Any other ethnic group Prefer not to say
Please specify:
Genetic Diagnosis*:
Contact's Telephone Number:
Contact's Email Address*:
How did you learn about the BINGO project:	Clinician Referral Charity or support group Other
Are you based in the UK?*:	Yes No
Message: