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Lactation Program Agreement of Usage
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I plan on using the Lactation Facility located in Building #
_______
for the
purpose of
expressing my breast milk, beginning on or about the date of
________________________________.
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I have received, read and understand all of the provisions of the Goddard
Workplace Lactation Program Policy and the Nursing Mothers' Lactation Room
Users Guide.
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I have attended an initial orientation with the Lactation
Room
SuperMom or at the Health Unit.
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I was provided with the Medela
Corporation's
instructions regarding the use of the Medela Classic breast pumps and the
proper
storage of breast milk.
-
I understand that in order to use the pump, I must
comply
with this agreement and purchase my own personal adapter kit.
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I understand
further that my participation in the program is subject to space
availability.
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I agree to abide by all provisions of the Goddard Lactation Facility
Policy and the
Nursing Mothers' Lactation Room User Guide. I understand that failure to
comply
with any of these provisions could be grounds for my termination from the
program.
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I agree that if I encounter any problems with the Classic pump,
or if I
have any concerns about the pump's operation, I will contact the building
SuperMom or the Program Coordinator before attempting to use the pump.
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I
agree
that the storage and transport of my expressed breast milk is my own
personal
responsibility.
I will / will not (circle one) be using the Medela Classic breast pump.
I will / will not (circle one) be using my own personally provided breast
pump.
__________________________________________________________
Nursing Mother's Signature and Date
____________________________
__________________________
Work Phone Number
Mail Code
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