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Have you ever received donor human milk directly from Mothers’ Milk Bank California (for example, for home use), rather than receiving donor milk provided by a hospital?
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Yes
No
How did you hear about the Healthy Start Fund?
Applicant Information
Baby's Full Name
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Baby’s Age
*
Please Select
1 to 4 weeks
1 to 3 months
3 to 6 months
6 months to 1 year old
1 year old or older
Primary Contact Person
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First Name
Last Name
Phone Number
Format: (000) 000-0000.
Email
*
example@example.com
Medical Need
What best describes your baby’s current situation? (Select all that apply)
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Very low birth weight
Premature (born before 37 weeks gestation)
Recovering from or preparing for a surgery/procedure — please specify
Gastrointestinal issues
Allergies or intolerances
Feeding or lactation challenges — please specify
At home and healthy
Other — please specify
Please Specify above selection
0/400
Required Documentation
Upload prescription or doctor’s note confirming medical need:
*
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📎 PDF, JPG, or PNG accepted
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Financial status verification
*
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Acceptable forms of documentation include proof of enrollment in a government assistance program—such as an EBT/SNAP benefits card, WIC card, or Medi-Cal card—or income verification documents. Families may submit the most recent tax return (first page only) or two recent pay stubs from each working adult in the household to demonstrate total household income.📎 PDF, JPG, or PNG accepted
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Optional Demographic Information
The following questions are voluntary and help us understand who we serve. This information allows us to meet reporting requirements and secure funding to expand access and services in the future. Responses are confidential and will be reported in aggregate only.
How do you identify your race and/or ethnicity?
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino/a/x
Middle Eastern or North African
Multiracial
Native Hawaiian or Pacific Islander
White
Prefer not to answer
Another identity (please specify)
Age Range
What's your age range?
Please Select
Under 18
18-24
25–34
35–44
45–54
55–64
65 or older
Prefer not to say
Preferred Language for Communication
What language do you generally prefer for communication? (Select all that apply)
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English
Spanish
Chinese (Mandarin or Cantonese)
Vietnamese
Tagalog
Korean
Prefer not to say
Another language - please specify
Consent
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I understand that this program provides up to 40 ounces per week for 2 weeks and that ongoing support may require separate insurance, provider referral, or private payment.
I consent to being contacted by Mothers’ Milk Bank California by phone, email, or text regarding donor programs, services, updates, and related outreach. I understand I can opt out at any time.
Milk Delivery Method
How would you like to receive your milk?
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Delivery
Pick-Up
Pick-Up Hours: Monday–Friday, 9:00 AM–3:00 PM (PST)
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