Louisiana Breastfeeding Coalition Membership 2020-21
Please complete the following questionnaire to register as an active LBC member for July 1, 2020 - June 30, 2021.
Please select your preferred pronouns
Credentials (If Applicable)
Title / Position (If Applicable)
Organization / Affiliation (If applicable)
Best Mailing Address - Address, City, State, Zip Code (Where you prefer to receive LBC mailings)
The following questions are optional, but responses are encouraged.
The LBC is committed to equity, diversity and inclusion. As a member organization of the United States Breastfeeding Committee, the LBC is working toward embracing and adopting core principles on Diversity, Equity and Inclusion (DEI). In an effort to show progress in DEI practices, Member Organizations of the USBC are asked to collect and share demographic data of their leadership and membership. The LBC Steering Committee, Bureau of Family Health breastfeeding staff and the USBC will have access to these data, in a de-identified manner. Your responses will be kept private and secure. The information will NOT be used for a discriminatory purpose or be linked to you personal profile.
Race / Ethnicity (optional, check all that apply)
American Indian or Alaskan Native
Black or African American
Native Hawaiian or Other Pacific Islander
To which gender identity do you most identify? (optional)
Cis man (identifies as a man and assigned male at birth)
Cis woman (identifies as a women and assigned female at birth)
Non-binary, gender fluid, or gender non-conforming
Prefer to self describe: (use "other" option below to self-describe)
Prefer not to say
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Terms of Service