Milk Bank WGL Donor Interest Form

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In order to become a donor, we ask that you:

- Are able to donate at least 100 ounces of milk* that we provide to premature and ill babies in the region.
- Are willing to undergo a confidential health history screening and obtain a free blood test for communicable diseases.

* Note: For bereaved families, there is no minimum milk donation or requirement to receive a blood test.

Email *

First Name *

Last Name *

Phone Number *

What is the best number to call you for your phone screening? Provide in the format 999-999-9999

Text Message *

Do you consent to receiving text messages during the donation process?

Yes

Milk Status

Give your best guess on approximately how much milk you currently have to donate. (There are no wrong answers!)

Still Pumping?

Yes

How did you hear about us?

Please select the ONE most important way you learned about milk donation.

My baby was a recipient of donor milk

I am a former milk donor

Hospital Staff / Nurse / Medical Professional

Lactation Consultant / Doula / Breastfeeding Support Office

Friend / Relative

Health Department / WIC Office

Hospital Flyer

Breast Milk Storage Magnet

Facebook / Instagram / Social Media

Milk Depot or Milk Dispensary

I met the Milk Bank at an event I attended

News Article

Internet Search

Other:

Why are you donating milk? *

What is the biggest reason you are choosing to donate milk?

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