MALC Membership Information Form
membership year January 1-December 31
Name and Credentials____________________________________________________
Home Address _______________________________________________________
City, State, Zip Code __________________________________________________ Phone ___________________________
Pager ______________________________ Are you currently IBCLC Certified? yes no Recertification year ________
Email address ___________________________________ Are you currently studying for IBCLC Certification? yes no
Business Name, Address, Phone, Fax, Email & Counties of Practice :
Do you sell/rent breastpumps or breastfeeding products? Yes No
Please elaborate
Employment Setting ( circle all that apply ) Private / Hospital / WIC / Clinic / Pediatrics Other____________________________
Would you like your information to be included in ( mark all that apply ):
____ Membership List ( mailed to members only )
____ IBCLC Referral Listing (MALC newsI web page)
_____ Conference Mailing List – not sold ( for current area conference – eg. MALC, LLL, etc. )
Please check area in which you would like to be involved
____Conference Committee ___Yearbook _____ World Breastfeeding Week Promotion _____Legal / political issues / lobbying
_____Board Position _____By-Law review/revision
Please list any programs/speakers that you would like to have present at MALC Meetings__________________________________________________________
______________________________________________________________________________________________________________________________
Send this form & payment to :
MALC Treasurer
43030 Alcott Circle , Novi , MI 48377
.
Make check payable to MALC for $25.