RKCAA Breastfeeding Peer Enrollment Form
1.
Client Information

First Name:
Last Name:
Home Phone:
Email Address:
emailaddress@xyz.com
Address 1:
Address 2:
City:
Postal Code:

2.

Cell phone number

 

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3.

Permission to communicate via text messages?

YES
NO
4.

Best time of day to contact you? 

 

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5.
Occupation
 

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6.

Employer Name

 

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7.

Full or Part-time?

Full Time
Part-time
8.

Age

14-17
18-24
25-44
Other  
9.

Race

Asian
Black
White
Biracial
Other  
10.

Ethnicity

Hispanic/Latino
Non-Hispanic
11.

Marital Status

Single
Married
Living with partner
Divorced
Other  
12.

Support Person's Name

 

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13.

When is your due date? 

 

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14.
Are you currently breastfeeding?
YES
NO
  • Comment:

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15.

If you are currently breastfeeding, what is the age of your infant?

 

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16.

Number of children previously breastfed? Ages of child/children?

 

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17.

Military Status?

Veteran
Active Service
N/A
18.

Insurance

Public (Badger Care)
Private
Other  
19.

I hereby give written and verbal consent for the RKCAA (Racine Kenosha Community Action Agency Breastfeeding Advocate) to contact myself and refer my name to other community resources. Signed,

 

50 characters left.