Me Breastfeed Registration For Lang’s Community Health Centre

Please select the date of the workshop you are registering for:

First Name:

Last Name:

Gender:

Email:

Phone Number:

Postal Code:

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

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?
[radio* support-person "Partner" "Child" "Relative" "Friend" "Other"]

Are you currently in your:
[radio* currently-in "First Trimester" "Second Trimester" "Third Trimester" "I am not currently Pregnant"]

When is your baby due?

What health care 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?
[radio* english-second "Yes" "No"]

The language I speak most often at home is:

What is your age?

What is your highest level of school completed?
[radio* school-completed "Grade 8" "High School" "College" "University" "Trade School"]

Do you currently smoke?
[radio* smoke "Yes" "No"]

Have You breastfed a child before?
[radio* breastfed-before "Yes" "No"]

For how long did you breastfeed?
[radio* how-long "Birth to 3 Months" "3 to 6 Months" "6 to 12 Months" "Over 12 Months" "I have never breastfed a child"]

Do you plan to breastfeed?
[radio* plan-to-breastfeed "Yes" "No" "Unsure"]

How confident are you in your knowledge about breastfeeding?
[radio* confident-knowledge "Very Confident" "Confident" "A Little Confident" "Not Confident"]

How confident are you in your ability to breastfeed?
[radio* confident-ability "Very Confident" "Confident" "A Little Confident" "Not Confident"]

How confident are you in your ability to prevent/solve breastfeeding problems?
[radio* confident-problems "Very Confident" "Confident" "A Little Confident" "Not Confident"]

How comfortable are/would you be breastfeeding your baby?
[radio* comfortable-breastfeeding "Very Comfortable" "Comfortable" "A Little Comfortable" "Not Comfortable"]

How comfortable are/would you be breastfeeding your baby in public (e.g. mall, restaurant, park, etc.)?
[radio* comfortable-public "Very Comfortable" "Comfortable" "A Little Comfortable" "Not Comfortable"]

Do you currently know where to go for breastfeeding support and resources in the community?
[radio* where-resources "Yes" "No" "Unsure"]

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.