Membership Enrollment Form

Name *

First Name Last Name

Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

E-mail *

Phone Number: *

Area Code Phone Number

ORGANIZATION MEMBERSHIP- Please provide the name of your organization and the name of the primary member.

(Optional)

Individual Membership - Please provide your name or name of your business.

(Optional)

Tell us about you! *

Professional, workplace, volunteer, credentials, breastfeeding parent/supporter etc ?

Pay by check

PABC Annual Membership $25.00

Check payable to: Pennsylvania Breastfeeding Coalition

Mail check to:

PA Breastfeeding Coalition
PO Box 4
Hannastown, PA 15635

Please mail the check at your earliest convenience.

If you do not want to pay by check, please see the PayPal form here: https://form.jotform.com/201284983703155

PABC Membership *

By becoming a PABC member (2020 - June 30, 2021) I agree to support the mission of the Coalition to facilitate community and statewide efforts to protect, support and promote breastfeeding as the cultural norm across the Commonwealth of Pennsylvania. PABC supports the International Code of Marketing Breastmilk Substitutes. I give PABC permission to record and use video/photograph(s) taken of me and/or my son/daughter during PABC sponsored meetings or events. Permission is also granted to use photographs supplied by members. The aforementioned photographs/video/recordings may be used for marketing and/or education purposes only

After you submit this form, please mail the check at your earliest convenience. Next, check your email to receive your membership verification letter, access to the members-only Facebook group and more!

PABC facilitates community and state wide efforts to protect, promote and support breastfeeding. Independent 501 (c) (3) non-profit. Pennsylvania Breastfeeding Coalition PO Box 4 Hannastown, PA - 641-715-3900 ext. 663535#

The official registration and financial information of Pennsylvania Breastfeeding Coalition may be obtained from the Pennsylvania Department of State by calling toll free, within Pennsylvania, 1-800-732-0999.

Need help? membership@pabreastfeeding.org or secretary@pabreastfeeding.org