EmailMe Form - Breastfeeding Support Program

Today's Date
MM / DD / YYYY
Name *
First Last
Campus Department
Phone
### - ### - ####
Email
Using your above email, would you like to receive information regarding upcoming parenting workshops and events on campus?
Yes
No
Use a different email
Email 2
Employee or Student ID Number
University Affiliation
Faculty
Post Doc/Visiting Scholar
Staff
Spouse/Partner of UC Berkeley Affiliate
Graduate/Professional Student
Visitor to Campus
UCOP or LBL
Other UC Affiliate
Undergraduate
Planned length of time to breastfeed:
6 months
2 years
1 year
Other
Other time length:
Planned date to return to work or school
Breastfeeding Support Program Needs (check all that apply)
Use a campus lactation room
Use the hospital-grade breast pump available in the lactation room
Order the HygieniKit (needed to use the lactation room's pump)
Attend the Breastfeeding Your Baby class
Purchase the AMEDA PURELY YOURS personal electic pump
Lactation Room Choices
Please select your lactation room preference. You may select up to three if needed.