Session Registration for Breastfeeding Support Circle
Choose your session, share your contact details, and complete the optional and required questions to reserve your spot.
Which session would you like to attend?
*
October 10, 2026 · Saturday
November 21, 2026 · Saturday
December 12, 2026 · Saturday
Full Name
*
First Name
Last Name
Pronouns
Email Address
*
example@example.com
Preferred Contact Method
*
Email
Text Message
Either
Mobile Number
Please enter a valid phone number.
Format: (000) 000-0000.
Baby's Age
*
Please Select
Pregnant/Expecting
Newborn (0–4 weeks)
1–3 months
3–6 months
6–9 months
9–12 months
12+ months
Current Feeding Method (select all that apply)
*
Exclusive breastfeeding
Breastfeeding + formula
Exclusive pumping
Formula feeding
Combination/other
What brings you to the Support Circle?
*
Food Allergies or Dietary Restrictions
Accessibility or Comfort Needs
Demographic Information (IDPH Grant Reporting)
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Race / Ethnicity (select all that apply)
*
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino/a/x
Middle Eastern or North African
Native Hawaiian or Other Pacific Islander
White / Caucasian
Multiracial / More than one race
Prefer not to say
Other
Primary Language
*
Please Select
English
Spanish
Arabic
Somali
Mandarin/Chinese
French
Other
County of Residence
*
Insurance / Coverage Type
*
Medicaid / CHIP / All Kids
Private / Employer Insurance
Marketplace / ACA Plan
Uninsured / No Coverage
Medicare
Prefer not to say
WIC Participation
*
Currently enrolled in WIC
Previously enrolled
Never enrolled
Not sure / Don't know
Reserve my spot
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