Breastfeeding Friendly Childcare Center Resource Kit Request Form Contact InformationName of Center Name of Requestor Title Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code PhoneFaxEmail Address* Website Address DemographicsIs this a family day home? yes no Is this a center based program? yes no How many sites are affiliated with this business? Is center licensed through DSS? yes no How many infants are currently enrolled? Between ages 0-3 months How many infants are currently enrolled? Between ages 2-6 months How many infants are currently enrolled? Between ages 6-12 months How many infants are currently enrolled? Between ages 12 months and over How many infants currently receive breastmilk? If you are not sure please estimate. Between ages 0-3 months How many infants currently receive breastmilk? If you are not sure please estimate. Between ages 3-6 months How many infants currently receive breastmilk? If you are not sure please estimate. Between ages 6-12 months How many infants currently receive breastmilk? If you are not sure please estimate. Between ages 12 months and over Staff TrainingHas center staff received any information or training on supporting breastfeeding? Please describe:Are you interested in having staff training on supporting breastfeeding? yes no How many staff members are currently employed with your center/centers? PolicyDoes center/centers currently have a work site lactation policy? yes no Does center/centers currently have a designated breastfeeding area? yes no Community ReferralsThe Virginia Special Supplemental Nutrition Program for Women, Infants and Children (WIC) provides nutrition education, breastfeeding promotion and support, supplemental nutritious foods, counseling, screening and referrals. The goal of the Program is to improve the health of pregnant women, infants and children (under 5 years) through better nutrition and access to health care. Does center/centers make referrals to the local WIC program? yes no Would you like to receive information about the WIC program to share with your clients? yes no
