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BECOME A DONOR

BEREAVED DONOR INTAKE FORM

Thank you for your interest in milk donation. By donating your milk you will be leaving a beautiful legacy for your baby and providing many premature and ill babies across the country the best start to life possible.

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Please review the Eligibility Criteria before completing this form. *Please note that bereaved donors are not required to meet a minimum amount for donation.

 

We will contact you by telephone to get started with the next phase of screening. If you have any questions about this form, please Contact Us. 

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For 24/7 peer support for bereaved parents you can contact the Pregnancy & Infant Loss Support Centre.

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For affordable breast pump rentals in Calgary contact the MOM Project.

Donor Information:

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Baby's Information:

Mother's Health Care Provider

Thank you for submitting! We'll be in touch shortly.

Bereaved Donor Intake Form
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