New Jersey Breastfeeding Coalition Membership & Renewal Form

The New Jersey Breastfeeding Coalition, Inc's mission is to promote, protect, and support breastfeeding by working collaboratively. By completing this membership form you are confirming your support for the mission of the NJBC, Inc.

Donations are encouraged but not required. To donate online, please use the Paypal Donate button on the membership page or mail your check to the New Jersey Breastfeeding Coalition, Inc. in care of Kay O'Keefe, 90 Marcellus Ave, Manasquan, NJ 08736. We are a non-profit and we flourish on donations. Make checks out to "The New Jersey Breastfeeding Coalition, Inc." Thank you.

Email *

Name *

Home Street Address *

City *

State *

Zipcode *

Personal Phone Number *

Affiliation

Workplace/Organization

My interest in breastfeeding is as (choose all that apply):

Advocate

IBCLC

CLC

CBC

Registered Nurse

Physician

Midwife

Peer Counselor

WIC Employee

Educator

Community Health Worker

Home Care Provider

Mother

Partner

Doula

Community Peer to Peer Breastfeeding Support Organization, please specify below in "other":

Other:

Gender you identify with:

Woman

Man

Non-binary

Prefer not to say

Other:

Clear selection

If other, how do you identify?

Age Range?

Less than 24

25-34

35-50

51-65

Over 65

Clear selection

Ethnicity?

Hispanic

Non Hispanic

Clear selection

Race (please choose all that apply)

Asian

Black or African American

Native American/Alaskan Native

Native Hawaiian/Pacific Islander

White

Prefer not to say

If other, what race do you identify with?

What interest area would you most like to be involved

Advocacy/Legal

Lactation Equity

Education

Community Engagement

Grant

Marketing/Communications (i.e. social media, website)

Other:

A copy of your responses will be emailed to the address you provided.

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