North Alabama Breast Pump Project Request Form
An Alabama Cohosh Collaborative program.
A Disclaimer About Preowned Breast Pump Distribution by ACC
Breast pumps are preowned, unless noted otherwise. With each preowned breast pump, you will receive new compatible breast pump accessories (flanges, tubing, duck bills, membranes, etc.) By providing your signature, you are acknowledging that you will receive a preowned breast pump that has been cleaned and checked for powering functionalities only. Please read the following statement and initial before continuing. I acknowledge that I am receiving a preowned breast pump and that there are certain inherent risks associated with retrieval of a preowned breast pump. I assume full responsibility for personal injury to myself and (if applicable) my family members, and further release and discharge Alabama Cohosh Collaborative for injury, loss or damage arising out of my or my family's use of or presence upon the facilities of Alabama Cohosh Collaborative, whether caused by the fault of myself, my family, Alabama Cohosh Collaborative or other third parties. I agree to indemnify and defend Alabama Cohosh Collaborative against all claims, causes of action, damages, judgments, costs or expenses, including attorney fees and other litigation costs, which may in any way arise from my or my family's use of or presence upon the facilities of Alabama Cohosh Collaborative. Any legal or equitable claim that may arise from participation in the above shall be resolved under Alabama law. The parties will attempt to resolve any dispute arising out of orrelating to this Agreement through friendly negotiations amongst the parties. If the matter is notresolved by negotiation, the parties will resolve the dispute using the below Alternative DisputeResolution (ADR) procedure. I HAVE READ THIS DOCUMENT AND UNDERSTAND IT. I FURTHERUNDERSTAND THAT BY SIGNING THIS RELEASE, I VOLUNTARILYSURRENDER CERTAIN LEGAL RIGHTS.
Signature
*
Powered by
Jotform Sign
Clear
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Infant's Due Date or Induction Date (Whichever is first) or Infant's Birth Date if already born.
*
-
Month
-
Day
Year
Date
Demographic Information
This information can help us when assessing community needs, and when sharing information about the breast pump donation program with potential funders. None of these questions are required, but by answering, you also help our organization know more on how to provide resources that might need to meet individual needs.
Please check all that apply regarding your racial and ethnic identity
White
Black or African American
Latinx
Asian
Native American
Other
Please check all that apply regarding your gender and sexual orientation
Straight
LGBTQ
Other
Do you currently have health insurance?
Private Insurance (BCBS, United HealthCare, Tricare, etc)
Alabama Medicaid
Not Insured
Other
Are you currently on WIC?
Please Select
Yes
No
Back
Next
Closed-System Breast Pump
A closed-system pump is one that is sealed off from the milk by a barrier (this feature is also called “overflow protection”). This is the most hygienic type of pump, as the barrier prevents milk from getting into the machine, which can make tubes and small pieces difficult to sterilize.
What brand of pump would you like? Please note that we aren't always able to supply your preferred brand of pump. If we have it in stock we will definitely send you the one you want. You will also receive accessories for the brand breast pump you receive. Accessories include, but are not limited to: flanges, tubing, membranes, charger adapter, etc.
Flange Size Matters. Please provide your flange size. View the images below for sizing support.
*
Please comment if you would like to specify the specific support you could benefit from. We will do our best to either provide you with that support or connect you with the best resources available.
We would love to know how you heard about this program! Let us know here.
Newsletter
Yes, subscribe me to this newsletter.
Thank you for completing your request form.
After your submission, there will be a Thank You page. Please read it, as it will have details on the next step and other resource information that may be available to you.
Continue
Continue
Should be Empty: