© 2015 by MothersMilkBankCharity Proudly created with
Stardust Graphics

 

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

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

If NO, proceed to PART B.   If YES, please answer the following questions.

3. Has your milk donation been stored for that period in a deep freeze facility?
4. Was your milk donation stored in sterile containers at the time of expressing?

PART B

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

If NO, proceed to PART D.  If YES, please answer the following questions.

OPTION 1:  For mothers who are currently breastfeeding

OPTION 2:  For expecting mothers who wish to breastfeed their own child and also contribute, if possible, to the Mothers’ Milk Bank.
 

Please note: If you have chosen OPTION 2 and are successful in your Donor Mother Registration, a Mothers’ Milk Bank consultant will contact you one month after your baby’s birth to see how you are progressing and whether you still wish to donate to the Mothers’ Milk Bank. At this time, you may also have stored breastmilk available that you would like to contribute as a one-off donation. When indicating your intent to donate and submitting this registration, the will be no obligation for you to contribute to the Mothers’ Milk Bank if you are unable or unwilling to do so at that time.
 

PART C

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

I would require a breast pump

I have my own/I have access to a breast pump

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.
 

Your 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.