Breast Pump Program Application
Greetings and Welcome to our Breast Pump Application Form! 

This is for our partner organizations only to submit requests for pumps. If you are not yet partnered with the Alliance for this program please reach out to us via our website and a team member will happy to contact you.  

For Self-Referrals: The Mother should contact us at the website and we will call her back to complete the application for her. 

We will accept applications for African American NICU Moms that:
  • Have a Mother that is a U.S. Citizen and of African American heritage or have a partner who is of this heritage.
  • Have had a NICU baby before and are at risk for another in their current pregnancy (high-risk pregnancy)
  • Have a baby currently in the NICU
  • Have a baby up to 30 days post-NICU discharge.  
  • Have had a NICU baby that resulted in a NICU Loss up to 30 days out.
  • This is an equalizer grant and so there is no income requirement.
For NICUs, Community, Non-Profit and State and Federal Government Organizations, Etc.:

1. The NICU, NICU-related organization or post-NICU related organization must be a partner with the Alliance for Black NICU Families before Applicants are accepted and reviewed for a breast pump.  Please contact us through our website: https://BlackNICUFamilies.org

2.  We will only accept an application from the agreed upon point of contact(s) at the approved NICU, NICU-related organization or post-NICU related organization partner.  

3.  Approved applications will have the pumps shipped to the point of contact at the NICU or NICU-related or Post-NICU related organization. The NICU/recipient must provide a street address and not a P.O. Box.  We will only deliver to a street address.

4. We do accept self-referrals.  In those cases we have a volunteer reach out by phone or Zoom to the mother to complete the application.  We cannot provide pumps for others outside our demographic of families due to the fact that grants were created and made to us with those specific terms.  We have to respect our funders, our families and appreciate your assistance with forwarding people to us only within the demographic we are focusing on directly.

5.  IMPORTANT: ADDRESS FOR SHIPMENT: It is the responsibility of the PUMP PARTNER to provide and confirm the shipment address whether it is to your organization or to the parent directly.. For large campus organizations, you should be contacting your own shipping and receiving department to inquire about the correct address, any special mail stop numbers, codes, etc.  A wrong address can result in a lost shipment and/or a shipment that is extremely delayed.  Please help us help you get these pumps in a timely manner by doing this small step. The Alliance does reserve the right to cancel a Pump Partnership due to too many lost pump shipments. Thank you for understanding!

6.  TIMEFRAME:  We will do our very best to turn around applications in a timely manner but please understand that we have a small team and that it takes time to order product and/or to ship out product from storage.  Assume a response on an application within 5 business days at most. Usually pumps are shipped out within a day but with holidays, weekends and unforeseen circumstances we cannot completely commit to this.  Thank you!
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Alliance for Black NICU Families - Breast Pump Grants
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