UNM Breastfeeding Support Program

Program Registration Form

UNM Breastfeeding Support Program

Administered by the UNM Women’s Resource Center

CONTACT INFORMATION

Date:______

Name:______

Phone:______Email:______

University Affiliation:  Faculty  Staff  Undergraduate Student

 Non Degree Student  Graduate/Professional Student  Post Doc/Visiting Scholar

 Spouse/Partner of UNM Affiliate  Other (Please specify):______

Campus Department:______

LACTATION STATION INFORMATION

Which campus lactation station would you like to use,

please rate stations by priority 1-5 (1=most use, 5=less use):

Main Campus:

The UNM Breastfeeding Support Program serves UNM students, staff, and faculty and their domestic partners. For more information call the UNM Women’s Resource Center 277-3716,email the program coordinator at , online at women.unm.edu, or Facebook: UNM WRC Breastfeeding Support Program.

__Centennial Library Room L259B (Ask for key at Circulation Desk)*

__Communication & Journalism

__Johnson Center Room 149

__Ortega Hall Room 235

__Student Union Building (Sign key in and out at Welcome Desk)*

__Women’s Resource Center*

__Zimmerman Library*

North Campus:

__Carrie Tingley Hospital*

__Domenici Education Center B 107A*

__Family Practice Bldg (Ask at Family

Practice Front Info Desk for Andrea

Rhodes, Charge Nurse or Office

Supervisor for key)*

__UNMH*

__UNM School of Law*

__Health Sciences Library & Informatics

Center Room 325*

__Nursing/Pharmacy Bldg B 70*

Start Date (estimated)______End Date (estimated)______

Days of the week/ times:______

ADDITIONAL INFORMATION

I would like to see the UNM Breastfeeding Support Program offer:

__A hospital grade pump in each lactation room__Attachments for sale

__Breastfeeding classes__Lactation consultant appointments

__Other:______

Is this your first experience with breastfeeding and pumping?  Yes  No

Do you own a personal electric breastpump?  Yes  No

Would you like more information on WIC services?  Yes  No

How did you learn about the UNM Breastfeeding Support Program? ______

You can drop-off, mail, email or fax this form to:

Women’s Resource Center Email to:

MSC06 3910Fax to: 277-2913

1 University of New Mexico

Albuquerque, NM 87131