Which dates are you available to train? (if you are available for more than one opportunity, please select all that apply)
Spring 2024 (May 10 - 11, 2024) Fall 2024 (Dates TBD)
What is your home address?
What is your age?
-- 15-20 21-25 26-30 31-35 36-40 over 40
What are your Pronouns? *optional
check one or more options for the set of pronouns you want people to use when they refer to you
--- She/Her They/Them Ze/Hir Xe/Xir He/Him Something Else
Is English your second language?
Yes No
What other languages can you speak?
What is your highest level of school completed?
-- Grade 8 High School College University Trade School
What is your postal code?
How did you hear about volunteering for the Breastfeeding Buddies peer support program of Waterloo Region? Please check all that apply.
Family/Friend Region of Waterloo Public Health (Website, nurse, program) Midwife Obstetrician Doctor/Nurse Practitioner Ontario EarlyOn Center Grand River Hospital Cambridge Memorial Hospital Had a Breastfeeding Buddy Attended the Me Breastfeed Workshop Attended the Baby & Me Breastfeeding Drop In Attended Virtual Programs Breastfeeding Buddies Website Breastfeeding Buddies Facebook Page None of the Above
Please list your work or volunteer experience that may be relevant to the Breastfeeding Buddies volunteer program.
Please upload a copy of your resume if you wish.
Please list two references we can contact during the application process. This should be someone who will say you are a supportive, reliable, and caring individual (does not need to be an employer, but should not be an immediate family member! A friend, coworker, teacher, neighbour, etc)
Reference 1 First Name *
Reference 1 Last Name *
Reference 1 Email
Reference 1 Phone Number
Relationship to you
Reference 2 First Name *
Reference 2 Last Name *
Reference 2 Email
Reference 2 Phone Number
Relationship to you
How old were you when your first child was born?
-- 15-20 21-25 26-30 31-35 36-40 over 40
Did you breastfeed (or chestfeed) your first child?
Yes No
Did you breastfeed (or chestfeed) your second child?
Yes No I do not have more than one child
The next section asks about your personal breastfeeding or chestfeeding experience. Please check all that apply (may be your own or someone very close from whom you have gained excellent insight).
Do you have experience with?
Pre-mature Birth Cesarean Section Twins Postpartum Depression/Anxiety Nipple Confusion Low Milk Supply High Milk Supply High Needs Baby (Fussy or colicky) Poor Latch Sore/Cracked/Bleeding Nipples Plugged Ducts Mastitis Slow Weight Gain Biting Lack of breastfeeding support (Family, friends, partner) Nursing Strike (Baby refuses to nurse) Tongue Tie Illness/Surgery (Child) Allergy (Child) Cleft Lip Cleft Palate Sleepy Baby Jaundice Pumping Thrush (Yeast) Breast Implants Breast Reduction Milk Storage Problems Labour/Delivery Returning to Work/School (While Breastfeeding)
Is there any other breastfeeding or chestfeeding experience you feel would be beneficial as a Breastfeeding Buddy (including any additional information from the above categories)?
This section asks about your personal life experience. Please check all that apply (may be your own or someone very close from whom you have gained excellent insight).
Do you have lived or living experience of any of the following? Please only share if you would be comfortable having this information as part of your 'helping profile'.
Please note that this information will be kept strictly confidential according to our privacy policy.
I am living on a limited income (I have had to visit food banks, I sometimes don't have money for rent) I am living in unstable housing (I am on a waiting list for for housing, I have stayed at a shelter) I am new to Canada (I have lived in Canada less than five years) I don't have many social supports (Family, friends, neighbours, community groups) Single parenthood Illness/Health condition (Mother) Surgery (Mother) Mental Health Addiction or Substance Use Domestic Violence/Abuse I prefer not to answer None of the above
Any other life experience you feel would be beneficial as a breastfeeding buddy? (including any additional information from the above categories).
What supports and or services did you use in your breastfeeding experience?
Family/Friends Physician Midwife Attended the Me Breastfeed Workshop Cambridge Memorial Hospital Breastfeeding Buddies Program Attended Breastfeeding Buddies Baby & Me Drop In Group(s)/Virtual Programs Had a Breastfeeding Buddy La Leche League Lactation Consultant Public Health Phone or Home Visit Community Support Site (Pre-Natal Nutrition, Busy Babies, Circle of Families, Playgroup, Breastfeeding Site) None of the above
Permissions and Consents
I give permission for Community Healthcaring KW and the Breastfeeding Buddies Program of Waterloo Region to use my name, address, and phone number to tell me about Breastfeeding Buddies of Waterloo Region programs/services, newsletters, and evaluations?
-- Yes No
I am willing to be contacted by a member of the Breastfeeding Buddies of Waterloo Region research team at some point in the future to learn more about the Lyle Hallman Grant and Study project and my possible participation?
(Consent can be withdrawn at any time. This will not affect your application or program participation in any way. Choosing yes gives our researchers permission to contact you to ask if you are willing to take part once you have been given more information about the study). Participating in this study is your choice (voluntary). You have the right to choose not to participate, and you have the right to withdraw from the study and stop your participation at any time. here will be no consequences to you or the services you receive.
-- Yes No
I am willing to be contacted by authorized students and volunteers about Breastfeeding Buddies of Waterloo Region activities?
-- Yes No
Emergency Contact First Name *
Emergency Contact Last Name *
Emergency Contact Phone Number *
Thank you for your interest in becoming a Breastfeeding Buddy! Your application will be reviewed and you will be contacted.
Please note there are a limited number of training spots. The 3 day training is free and attendance at all three days is mandatory. Babies are welcome in the training room, and childcare spots are available for older siblings