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 serving your area – please check here to find its website!

If there is a specific reason you prefer to donate through our bank (e.g. moving to our area soon, a previous connection to a hospital we serve), please email milkdonor@themilkbank.org – we are likely to support you! Again, thank you for reaching out and we wish you the best!
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 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 30 days?*

YesNo
If you are approved, are you willing to complete a 5-minute online follow-up form at least every two months for as long as you are donating milk?*

YesNo

You have our deepest sympathies for your loss. Please know that we are here to support you no matter what you decide about milk donation; please visit our Bereavement Services page to learn more.

If you know you want to start the donor approval process, our only request is that you wait until after delivery to do so, since much of the information we'll need will be unknown until then.

If you need to discuss any questions about the process to help decide your next steps, please call 317-536-1670, select zero, and ask to talk to our Bereavement Coordinator.

To continue the approval process now by completing our online intake form, please hit the "Submit" button below.
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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