Get PUMPed!

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 complete all questions. If an item does not apply, please indicate N/A.
How did you hear about? *

Caregiver Information

Is the biological mother deceased? *

Child's Information

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Additional Information

Does the child currently have medical insurance (medicaid included)? *
Our milk master is located in Sanford, FL. If approved, would you be able to make accommodations to travel and pick up your milk? *