Georgia Team Nursing Moms Program Registration Form
Please provide the following information, print out, review, and sign the following forms, then return in campus mail to: Donna Redmon, Faculty Career Development Services, mail code 0330. (Mailing address is: 225 North Avenue, Administration Building, Room 12, Atlanta, GA 30332-0330) First Name Last Name Job Title Department ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ______________________________________ Mail Code ___________
Email __________________________________________________________________ Work Phone ______________________ Home Phone ________________________
Home Address____________________________________________________________ City _______________________________________ _________________________ __________________________________________ State__________________
Zip Code
Baby’s Due Date/Date of Birth Is this your: first baby second baby other □ □ □
Comments ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________
Program Started by the NSF ADVANCE Program www.advance.gatech.edu
Georgia Tech Nursing Moms Program Agreement
I plan to use the nursing moms centers for the purpose of expressing milk / nursing my baby (circle one), beginning on or around the date of ____________________. I have read and understand all of the provisions of the Georgia Tech Lactation Program Policy. I have completed online or onsite training. I have been provided with the Medela Corporation’s instructions regarding the use of the Medela Lactina® Plus breast pump and the proper storage of breast milk. I understand that in order to use the pump, I must comply with this agreement and purchase my own personal adapter kit. I understand further that my participation in the program is subject to space availability. I agree to abide by all provisions of the Georgia Tech Nursing Moms Program Policy. I understand that failure to comply with any of these provisions could be grounds for my termination from the program. I agree that if I encounter any problems with the pump, or if I have any concerns about the pump’s operation, I will contact the SuperMom for the building’s lactation center or the FCDS office before attempting to use the pump. I agree that the storage and transport of my expressed breast milk is my own responsibility. I will / will not (circle one) be using the Medela Lactina® Plus breast pump. I will / will not (circle one) be using my own personally provided breast pump. I have / have not (circle one) reviewed the GA Tech Nursing Moms Program Policy. ___________________________________________ Nursing Mother’s
Print Name: _____________________________________
_________________ Signature Date
Program Started by the NSF ADVANCE Program www.advance.gatech.edu
Georgia Tech Nursing Moms Program Policy
1. The Nursing Moms Centers (NMCs) are open to Georgia Tech faculty, students, and staff. You may bring your baby in to be fed. You are also welcome to bring your personal pump. However, if you intend to use the pump provided at the center, you must first complete training and return your signed agreement to the FCDS office. 2. Personal pump kits may not be left in the NMCs. 3. The person whose name appears on an NMC schedule for a designated time has priority to use the center at that time. 4. It is the responsibility of everyone using the NMCs to clean up any spills they make while using the lactation center. Cleaner is provided in each of the centers. Please notify the FCDS office if you are out of cleaner. 5. Breast milk may be stored in the refrigerator of an NMC with the permission of that location's SuperMom. The refrigerator will be kept locked, so you must contact the SuperMom to gain access to the refrigerator. 6. It is your responsibility to notify the FCDS office if you discontinue use of the NMC(s). 7. News about the Nursing Moms Program will be distributed via e-mail to all registered participants. Please be sure the FCDS office has your current e-mail address.
FCDS – Faculty Career Development Services Contacts: Donna Redmon, 404.894.5058 or donna.redmon@carnegie.gatech.edu Monique Tavares, 404.385.0117 or monique@gatech.edu
Program Started by the NSF ADVANCE Program www.advance.gatech.edu