Please select the date of the workshop you are registering for:
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First Name *

Last Initial *

Email *

By checking this box, you are giving permission for the Breastfeeding Buddies Program to receive this form via email and use your email address to communicate with you. While all precautions are taken to ensure security and privacy, email can be vulnerable to misuse. Please do not include any confidential health information on the form.

Phone Number *

Postal Code *

We want to know who we're reaching! Please select the region where you live:
Waterloo RegionGuelph-WellingtonLambtonGTAHamilton/NiagaraOttawa/Northern OntarioOther

How did you hear about the Me? Breastfeed Workshop? Please check all that apply.
Family/FriendRegion of Waterloo Public Health (Website, Nurse, Program)MidwifeDoctor/Nurse PractitionerObstetricianOntario EarlyOn CenterGrand River HospitalCambridge Memorial HospitalBreastfeeding Buddies WebsiteSocial Media (Facebook, Instagram, Twitter)Print Media (Poster, Pamphlet, Postcard)North/West Lambton CHCGuelph CHCNone of the Above

Why do you want to attend the Me? Breastfeed Workshop? Please check all that apply.
I want more information about breastfeedingI need help with breastfeeding problemsI want to meet and learn from other breastfeeding momsI am looking for other breastfeeding resources in the communityI am a current or future birth/postpartum worker looking for professional development

We encourage mom's to bring a support person with them who can help support them with breastfeeding. Who are you planning on attending the Me? Breastfeed Workshop with?
PartnerChildRelativeFriendOther

Are you currently in your:
First TrimesterSecond TrimesterThird Trimester

When is your baby due?

What healthcare provider do you see most often during your pregnancy? Please check all that apply.
DoctorNurse PractitionerObstetricianMidwifeI have not seen a healthcare provider

We would like to know who we are reaching at the workshops. Please check all that apply to you.
I am living on a limited income (e.g. I have had to visit a food bank, I sometimes don't have money for rent)I am living in unstable housing (e.g. I am on a waiting list for housing, I have stayed at a shelter)I am new to Canada (I have lived in Canada less than ten years)I don't have many social supports (e.g. Family, friends, neighbours, community groups)None of the above

Is English your second language?
YesNo

The language I speak most often at home is:

What is your age?
15-2021-2526-3031-3536-40over 40

What is your highest level of school completed?
Grade 8High SchoolCollegeUniversityTrade School

Do you currently smoke?
YesNo

Have You breastfed a child before?
YesNo

For how long did you breastfeed?
Birth to 3 Months3 to 6 Months6 to 12 MonthsOver 12 MonthsI have never breastfed a child

Do you plan to breastfeed?
YesNoUnsure

Please indicate your level of confidence with the following:
How confident are you in your knowledge about breastfeeding?
Very ConfidentConfidentA Little ConfidentNot Confident

How confident are you in your ability to breastfeed?
Very ConfidentConfidentA Little ConfidentNot Confident

How confident are you in your ability to prevent/solve breastfeeding problems?
Very ConfidentConfidentA Little ConfidentNot Confident

Please indicate your level of comfort with the following:
How comfortable are/would you be breastfeeding your baby?
Very ConfidentConfidentA Little ConfidentNot Confident

How comfortable are/would you be breastfeeding your baby in public (e.g. mall, restaurant, park, etc.)?
Very ConfidentConfidentA Little ConfidentNot Confident

Do you currently know where to go for breastfeeding support and resources in the community?
YesNoUnsure

Congratulations on taking your first steps on your Breastfeeding Journey! We look forward to meeting you at the Me? Breastfeed workshop.

If you require immediate assistance or have concerns about your baby's health, please contact your health care provider. This service is not intended to replace medical care or crisis support.

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