Milk Donor Interest Form 8.2024

Milk Donor Interest Form
Thank you for taking your first step toward becoming a lifesaving milk donor!

Please respond honestly to the following quick questions to learn what is involved in the approval process!
Your Name*

First NameLast Name
Your Date of Birth*

MonthDayYear
Date
Your Baby's Date of Birth*

MonthDayYear
Date
Your Phone Number*
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Thank you for your interest in becoming a milk donor – we are so grateful for your big heart!

We do not typically approve donors residing in your area due to the shipping costs associated with the distance. The good news is that there is another milk bank closer to you – please click here to find its website!

If there is a specific reason you strongly prefer to donate through our bank, such as having a connection to a hospital we serve or if you are a Deloitte employee interested in their LSHC Working Parent Initiative Collaboration, please let us know by emailing milkdonor@themilkbank.org!

Again, thank you for reaching out and we wish you the best!
Thank you for your interest in becoming a milk donor – we are so grateful for your big heart!

We do not typically approve donors residing in your area because there is a partner milk bank serving Illinois and Wisconsin – please click here to learn about donating through the Mothers' Milk Bank of the Western Great Lakes!

If there is a specific reason you strongly prefer to donate through our bank, such as having a connection to a hospital we serve or if you are a Deloitte employee interested in their LSHC Working Parent Initiative Collaboration, please let us know by emailing milkdonor@themilkbank.org!

Again, thank you for reaching out and we wish you the best!
Thank you for your interest in becoming a milk donor – we are so grateful for your big heart!

We do not typically approve donors residing in your area because there is a partner milk bank serving Oklahoma and Kansas – please click here to learn about donating through the Oklahoma Mothers' Milk Bank!

If there is a specific reason you strongly prefer to donate through our bank, such as having a connection to a hospital we serve or if you are a Deloitte employee interested in their LSHC Working Parent Initiative Collaboration, please let us know by emailing milkdonor@themilkbank.org!

Again, thank you for reaching out and we wish you the best!
Thank you for your interest in becoming a milk donor – we are so grateful for your big heart!

Just so you know, our bank primarily serves Indiana, Kentucky, and Missouri. If you'd like your milk to stay closer to home, please find your closest bank here. They may also have convenient drop-off sites near you.

If you'd like to continue the approval process with us, we'll be happy to work with you and provide free shipping supplies - please continue below if that's what you prefer!
Which of the following is closest to the reason you’re exploring milk donation?*

I have an oversupply or frozen stash; I’m ready to start donating now to help babies!I previously donated to The Milk Bank and expect to have extra milk to donate again!I recently experienced, or anticipate, loss of a pregnancy or infant and want to pay that milk forward.I'm not ready to donate yet, but am curious about donation and want to learn more.

Are you ready and willing to make a donation of your human milk within 30 days of receiving our approval?*

YesNo
Are you able to complete a brief (5-15 min) phone screening and online information form covering health and medication history within the next 10 days?*

YesNo
Are you ready and willing to schedule and complete a blood draw, at no cost to you, within the next 3 weeks?*

YesNo
If you are approved, are you willing to keep us updated about any changes to your health, medications, or lifestyle that are relevant to milk safety?*

YesNo

You have our deepest sympathies for your loss, and we’re honored to help support you as you navigate this difficult time – regardless of whether you end up donating or not.

If you’re sure you want to move forward with the milk donor approval process, please check the box below and click Submit; you’ll then be redirected to the next step in the process. We only ask that you wait until after delivery to complete that step, as much of the information needed will be unknown until then.

If you have questions before moving on to that step, please feel free to contact us at milkdonor@themilkbank.org or call us at 317-536-1670 and ask to speak with our Bereavement Coordinator. You can also click here to learn more about available supports, including around supporting or suppressing lactation.

Thank you for reaching out to explore the possibility of donating and our services.
Do you need an interpreter? (¿Necesita un intérprete?)

Yes/SíNo
What is your preferred language? (¿Cual es su idioma preferido?)
Thank you for taking the time to complete this form! Once you hit the "Submit" button, you'll receive instructions regarding your next steps.
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