BALA Membership Application

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Thank you for your interest in BALA! Once this application and your $50 dues have been received, you will receive an email from the BALA membership coordinator. Dues can be sent via PayPal at bayarealactationassociates@gmail.com or email for treasurer's address if you want to pay by check.

Email *

Name: Last, First please *

Credentials: *

Company/Organization Name:

Title/Role:

Primary Mailing Address:

City, State & Zip:

Mobile Phone Number:

Work Phone Number:

Email Address: *

Company Website:

Do you rent breast pumps? *

Yes

Required

Professional Activities:

Private practice

Staff IBCLC in hospital or other setting

Other:

Professional Focus:

Breastfeeding

Birth assistance (doula/midwife/nurse)

Childbirth education

OT/PT/SLP

Cranial Sacral Therapist

Other:

Would you like to be listed in our Find a Lactation Consultant public BALA directory (for IBCLCs only)? *

Yes

Required

BALA is interested in increasing its outreach to underrepresented and underserved communities. If you need help or want to help - here is one option. Please include on PayPal. I will donate to the BALA Scholarship for Diversity Support and Outreach, and Dues Assistance the following amount:

$10

$25

$50

Other:

Clear selection

I am a member of an underrepresented / underserved community. I request assistance paying this year's dues of $50. I am able to pay this much:

Submit

Clear form

Never submit passwords through Google Forms.

Forms

This content is neither created nor endorsed by Google.