Donate Milk Registration Form

DONOR MOTHER
Registration Form
 
Thank you for undertaking the Donor Mother Registration Process.
 
Please answer all applicable questions truthfully and to the best of your ability.

PART A

I wish to make a one-off donation of stored breastmilk to the Mothers’ Milk Bank

PART B

I wish to become an ongoing milk donor to the Mothers’ Milk Bank

PART C

Would you require a breast pump with your Donor Kit, if accepted as a Mothers’ Milk Bank Donor?

PART D

Are there any reasons why you may be restricted from giving blood?

(ie. illness, disease, having lived in the United Kingdom between the years 1982-1995)

Do you presently or have you recently taken any medications which might exclude you from becoming a Mothers’ Milk Bank Donor?
Are there any other reasons that you can think of, which might exclude you from becoming a Mothers’ Milk Bank Donor?

(ie. smoker, drug user, consume large quantities of caffinated/stimulant beverages, recent blood transfusion)

Do you have any specific questions with regards to becoming a Mothers’ Milk Bank Donor?

PART E

I,

hereby certify that, to the best of my knowledge,

all of the information I have provided is correct and I have answered all questions truthfully.
 

Signature *

PART F

The following section is optional, but we would really appreciate your assistance and consideration in taking the time to answer these additional questions.

Thank you!

I would like to join the Mothers’ Milk Bank Mailing List and be updated on Mothers’ Milk Bank news and events.
I would like to register as a Mothers’ Milk Bank volunteer, if and when I can be of assistance.
I would be interested in assisting the Mothers’ Milk Bank in their fundraising endeavours.
How did you hear about the Mothers’ Milk Bank? (Please check any or all of the following)

You will be emailed a copy of this form.

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Postal Address

PO Box 806 
Banora Point NSW 2486

D12 -1 Eastern Avenue, Airport Central, Bilinga, Qld 4225 

Call Toll Free 1300 437 311

SMS 0480 024 170

24 Hours 7 Days a week

Contact hours

8am to 5pm

Monday to Friday