In order to list your name in the Breastfeeding Resources and Support section of the Breastfeeding Resource Directory, you must be a Certified Lactation Professional, a Licensed Heath Care Practitioner or a La Leche League Leader. In addition to submitting the information below, you must also send a copy of your license or certification (see instructions at the end of this form) for ANY credentials that you want to have listed.

Name of person submitting form (required)

Name:

Email Address:

Phone Number:

Location / Contact Information (list exactly as you wish to appear in directory) (required)

Name and Credentials:

Business / Organization Name:

Address:

Address 2:

City / Town:

State:

ZIP:

Email Address:

Phone Number:

Secondary Contact Information (list only what is applicable)
(this will be published in the directory)

Contact Name and Credentials:

Email Address:

Phone Number:

Web address

Professional License and/or Lactation Credentials (list all that apply) (required).
NOTE: You MUST be a Certified Lactation Professional, a Licensed Health Care Practitioner or a La Leche League Leader to be included in the directory.

MDRNRDRPTOTRIBCLCCLCCLECLECLa Leche League Leader
Other (please specify)

Please check all services provided (required).

Inpatient Consultations (hospital)Outpatient Consultations (hospital)In-office ConsultationsIn-home ConsultationsPump Sales and/or RentalsProduct SalesSupport GroupPhone SupportPrenatal ClassesNew Parent ClassesEmployee Support Programs
Other (please specify)

Please specify to whom your services are available (required).

General PublicOur Hospital PatientsSpecific Program Participants
Other (please specify)

Languages in which services are offered (required).

EnglishSpanish
Other (please specify)

Days/Hours of Service (required).

After you submit this information, YOU MUST SEND A COPY OF YOUR LICENSE OR CERTIFICATION for ANY credentials you would like listed. You may scan and e-mail the copy to directory@breastfeedventura.org, or fax a hard copy to:

Attn: Patty Zoll
Fax: 805-658-4535

or upload it here:

We will keep your information on file for the next update of the breastfeeding resource directory. For questions or a physical mailing address to mail your certification copy, please e-mail directory@breastfeedventura.org.