Private Space for Lactation

Private Space for Lactation
Valencia College is committed to continue supporting new mothers returning back to work by providing them with the option to use a private space for the purposes of expressing breast milk. In order to request access to a Nursing Mother’s Room, please complete and submit the following information. For questions, you may contact Joanna Victoria (jvictoria2@valenciacollege.edu, 407-582-3801).
What type of request is this? *

New Request Walk-In Cancellation
Who is completing this form? *

A nursing mother A Valencia employee submitting a request for a nursing mother
Nursing Mother Information
I am a

Valencia Employee Valencia Student Visitor
The Nursing Mother is a

Valencia Employee Valencia Student Visitor
Name *

First Name Last Name
Atlas Username
Valencia ID (VID)
Email *
example@example.com
Phone Number *

Area Code Phone Number
Location/Campus for Nursing Mothers Room: *
Valencia Employee Information
Valencia Employee Name *

First Name Last Name
Atlas Username *
Valencia Employee VID
Valencia Employee Email *
example@example.com
Appointment
What type of reservation is this? *

Single Appointment Reoccurring Appointment
Single Appointment

Month Day Year
Date
Start Time

: Hour Minutes AM/PM Option
End Time

: Hour Minutes AM/PM Option
Select Day(s) for Reoccurring Appointment

Monday Tuesday Wednesday Thursday Friday Saturday Sunday
From

Month Day Year
Date
To

Month Day Year
Date
Start Time

: Hour Minutes AM/PM Option
End Time

: Hour Minutes AM/PM Option
Do you need to request a second appointment time on the same day(s)?

Yes No
Start Time

: Hour Minutes AM/PM Option
End Time

: Hour Minutes AM/PM Option
Appointment Cancellation
What type of cancellation is this? *

Single Appointment Reoccurring Appointment
Single Appointment Date

Month Day Year
Date
Time

: Hour Minutes AM/PM Option
Reoccurring Appointment From

Month Day Year
Date
Time

: Hour Minutes AM/PM Option
To

Month Day Year
Date
Time

: Hour Minutes AM/PM Option
Additional Request Information
Acknowledgements
Organizational Development & Human Resources (ODHR) Access Services Office will review your request and contact you after your request has been processed.
Should be Empty:

Private Space for Lactation

Nursing Mother Information

Valencia Employee Information

Appointment

Appointment Cancellation

Acknowledgements