Lactation Supply Form – Child Advocacy

Pumping Pantry Order Form

Lactation supplies are available free of charge to all Gratiot County residents that are currently lactating. Once we receive your Order Request, a Child Advocacy staff member will contact you to coordinate a pick-up day and time.

For additional support and resources, please visit gcbreastfeedingcoalition.com

"*" indicates required fields

Personal Information

Name*

First Last

Address*

Street Address City ZIP / Postal Code

Phone*

Email*

Age of breastfed child*

Does your child exclusively receive breastmilk?*

Are you experiencing any difficulties (low supply, frequent clogged ducts, nipple pain, etc.)?*

Brand of breast pump*

Order Request

Flanges

If you are unsure of your nipple size, we have rulers available.

Pump parts (membranes, duck bills, tubing, etc.)

Disposable Nipple Pads (10/week)

Reusable Nipple Pads (2/week)

Storage Bags (10/week)

Additional information or items requested:

I am interested in meeting with the Breastfeeding Coalition Coordinator for more 1:1 lactation support

I understand that specific brands, sizes, and item types are based upon donations and may not be available*

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Pumping Pantry Order Form

Personal Information

Order Request

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