Me Breastfeed – Breastfeeding Buddies

Please select the date of the 2 hour workshop that you are registering for:

Please select your due date month (we recommend taking this session in your final 2 months of pregnancy):

First Name *

Last Name *

Email *

Name of Person Who Will Attend With You *

By checking this box, you are giving permission for the Breastfeeding Buddies Program to receive this form via email and use your email address to communicate with you. While all precautions are taken to ensure security and privacy, email can be vulnerable to misuse. Please do not include any confidential health information on the form.

By Checking This Box you confirm you have registered for a KEyON Account**
KEyON is a digital sign in system that that is mandatory in order to attend family programming at any Early ON Centre in Ontario. (Early ON Centres are welcoming places that offer a range of services and resources, where you can: join fun activities such as reading, storytelling, sing-alongs and games. get advice from professionals trained in early childhood development. find out about other family services in your community).
For Child and Family Safety, each parent (to be) who is attending our class at Early ON Centre, will need to register for a Free KEyON Account. If you are attending the class with a support person, they will need to show government issued I.D. to attend. To register for an Early ON account, please follow this link and then return to this page to complete your registration for your Prenatal Workshop. https://www.keyon.ca/en/Account/Register
** if this is a barrier for you, please email bfbuddies@healthcaringkw.org and we will find an alternate solution. [/KEyON]

Phone Number *

Postal Code *

We want to know who we're reaching! Please select city or township you live in most often:
CambridgeKitchenerWaterlooNorth DumfriesWellesleyWilmotWoolwichOutside of Waterloo RegionPrefer Not To Answer

Please select the township/city where you live: CambridgeKitchenerWaterlooNorth Dumfries (e.g., Ayr, Roseville)Wellesley (e.g., Linwood, St. Clements, Wellesley)Wilmot (e.g., Baden, New Dundee, New Hamburg)Woolwich (e.g., Breslau, Conestogo, Elmira, St. Jacobs)

How did you hear about the Me? Breastfeed Workshop? Please check all that apply.
Family/FriendRegion of Waterloo Public Health (Website, Nurse, Program)Attended the Prenatal Preview session at Blue HeronMidwifeDoctor/Nurse PractitionerObstetricianOntario EarlyOn CenterGrand River HospitalCambridge Memorial HospitalCommunity Healthcaring KWBreastfeeding Buddies WebsiteBreastfeeding Buddies Prenatal PathwaySocial Media (Facebook, Instagram, Twitter)Print Media (Poster, Pamphlet, Postcard)North/West Lambton CHCGuelph CHCNone of the Above

Why do you want to attend the Me? Breastfeed Workshop? Please check all that apply.
I want more information about breastfeedingI need help with breastfeeding problemsI want to meet and learn from other breastfeeding momsI am looking for other breastfeeding resources in the communityI am a current or future birth/postpartum worker looking for professional development

Please note: Space in the Breastfeeding Buddies Me Breastfeed session is reserved for expecting parents. If you hope to observe the session in a professional capacity, please have a representative from your organization reach out to mbuckner@healthcaringkw.org. Observation spaces will be considered on an extremely limited, prearranged basis only.

We encourage mom's to bring a support person with them who can help support them with breastfeeding. Who are you planning on attending the Me? Breastfeed Workshop with?
PartnerChildRelativeFriendOther

Are you currently in your:
First TrimesterSecond TrimesterThird TrimesterI am not currently Pregnant

Please note: Space in the Breastfeeding Buddies Me Breastfeed session is reserved for expecting parents. If you have any questions, please reach out to the team at bfbuddies@healthcaringkw.org

What is your baby's due date?

What healthcare provider do you see most often during your pregnancy? Please check all that apply.
DoctorNurse PractitionerObstetricianMidwifeI have not seen a healthcare provider

We would like to know who we are reaching at the workshops. Please check all that apply to you.
I am living on a limited income (e.g. I have had to visit a food bank, I sometimes don't have money for rent)I am living in unstable housing (e.g. I am on a waiting list for housing, I have stayed at a shelter)I am new to Canada (I have lived in Canada less than ten years)I don't have many social supports (e.g. Family, friends, neighbours, community groups)None of the above

Is English your second language?
YesNo

The language I speak most often at home is:

What is your gender?
FemaleMaleTransgenderTwo-spiritIntersexDo not knowAnother (please specify)

Which of the following best describes your racial or ethnic group?
First Nations/Indigenous (e.g., Inuit, Métis)Asian – East (e.g., Chinese, Japanese, Korean)Asian – South (e.g., Indian, Pakistani, Sri Lankan)Asian – South East (e.g., Malaysian, Filipino, Vietnamese)Black – African (e.g., Ghanaian, Kenyan, Somalian)Black – Caribbean (e.g., Barbadian, Jamaican)Black – North American (e.g., Canadian, American)Indian – Caribbean (e.g., Guyanese with origins in India)Latin American (e.g., Argentinean, Chilean, Salvadorian)Middle Eastern (e.g., Egyptian, Iranian, Lebanese)White European (e.g., English, Italian, German, Portuguese)White North American (e.g., Canadian, American)Mixed heritage (e.g., Black-African and White-North American)Do not knowAnother, please specify

What is your age?

What is your highest level of school completed?
Grade 8High SchoolCollegeUniversityTrade School

Do you currently smoke?
YesNo

Have You breastfed a child before?
YesNo

For how long did you breastfeed?
Birth to 3 Months3 to 6 Months6 to 12 MonthsOver 12 MonthsI have never breastfed a child

Do you plan to breastfeed?
YesNoUnsure

Please indicate your level of confidence with the following:
How confident are you in your knowledge about breastfeeding?
Very ConfidentConfidentA Little ConfidentNot Confident

How confident are you in your ability to breastfeed?
Very ConfidentConfidentA Little ConfidentNot Confident

How confident are you in your ability to prevent/solve breastfeeding problems?
Very ConfidentConfidentA Little ConfidentNot Confident

Please indicate your level of comfort with the following:
How comfortable are/would you be breastfeeding your baby?
Very ConfidentConfidentA Little ConfidentNot Confident

How comfortable are/would you be breastfeeding your baby in public (e.g. mall, restaurant, park, etc.)?
Very ConfidentConfidentA Little ConfidentNot Confident

Do you currently know where to go for breastfeeding support and resources in the community?
YesNoUnsure

Congratulations on taking your first steps on your Breastfeeding or Chestfeeding Journey! We look forward to meeting you at the Me Breastfeed workshop.

If you require immediate assistance or have concerns about your baby's health, please contact your health care provider. This service is not intended to replace medical care or crisis support.

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