Recipient Application

Please complete the following application to the best of your ability. The personal and identifying information collected in this application will be held in strict confidence and shared only with the Board members of Get PUMPed, Inc. Generalized data about your child may be shared with donors, grantors and other interested parties.

We find that donors and grantors are often more willing to provide assistance when they feel more connected with those receiving breastmilk. We would be most appreciative if you are willing to allow us to share additional information about the circumstances behind your need and/or your child's picture with those stakeholders. This, however, is not a requirement for receiving milk.

Please provide as much information as you can when completing the application. We are only able to take a limited number of families at this time and are unable to guarantee that everyone who applies will receive milk. The board of directors will be reviewing each case thoroughly.

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number (Home) *

Alternate Phone Number (Cell)

Email Address *

Best Method and Time to Contact You *

How did you hear about? *

Please tell us specifically who referred you. *

Name of child needing breastmilk *

Please explain the situation and why you have chosen to seek donated breast milk. *

Caregiver Information

Is the biological mother deceased? *

No

Yes

Unsure

If your reason for applying for donor milk is due to the biological mother's medical condition, please tell us about the current diagnosis, treatment, and prognosis. Please be prepared to provide documentation from a physician. Please include specific medications when discussing treatment. *

Who is/are the child's primary caregiver(s)? *

Who will be primarily responsible for feeding the child breast milk? Is this person knowledgable or willing to become knowledgable about the safe handling and storage of breast milk? *

Is the biological mother currently lactating? If so, approximately how many ounces per day are being produced, and can the child safely consume this milk? If the biological mother is not available to the child (foster or adoptive situation), please indicate. *

Has a lacation specialist been consulted about breastfeeding options? Please describe in detail. *

Child's Information

Original due date as determined by care provider during routine prenatal care: * +

Actual birth date * +

Child's gestational age at time of birth *

Did the child stay in the NICU? *

Birth weight *

Child's current weight *

Approximately how much milk or formula is the child consuming per day? *

Medical complications related to prematurity *

Other medical or health-related issues *

Has the child ever had formula? If so, please explain the circumstances. *

If the child has had formula, how was it tolerated? *

Additional Information

Does the child currently have medical insurance (medicaid included)? *

Yes

No

Has a HMBANA milk bank been contacted for donor milk? If so, what was the outcome, and if applicable, has insurance approved or denied coverage for donor milk? *

Has an attempt been made to procure milk from any other sources? If so, please explain.

Ex:
Eats on Feets: https://www.facebook.com/EOFflorida
Human Milk 4 Human Babies: https://www.facebook.com/hm4hbflorida *

Are you interested in exclusively feeding the child breast milk? If so, for how long, and approximately how much milk does the child consume each day? "Exclusively" means no other sources of nutrition at all, i.e. no solid food and no formula. *

Are you interested in supplementing the child's diet with breast milk? If so, for how long, and approximately how much milk are you requesting each day? *

Our milk master is currently located in Deland, FL. If approved, would you be able to make accommodations to travel and pick up your milk? *

Yes

No

Will you allow us to share your/your child's story (anonymously) with our donors and on social media? Doing so helps promote our organization and recruit more breastmilk donors. Your response has no bearing on the consideration of your application. *

Yes

No

I acknowledge that although Get PUMPed! does its best to screen milk donors through blood work, questionnaires, and medication screenings, it is ultimately the recipient family's responsibility to maintain the infant's health. I understand that Get PUMPed! milk donors may be taking L1 and/or L2 medications, deemed "safe" or "probably safe" for breastfeeding children, respectively. *

Yes

No

The cost of formula is approximately $0.20 per ounce. Would you be willing to offer a donation of a comparable amount to Get PUMPed, Inc. to help us defray costs and expand our ability to help additional families? Your ability to pay has no bearing on the consideration of your application. *