APPLICATION FOR BREASTFEEDING RESOURCE DIRECTORY INSTITUTIONAL PROVIDER OF LACTATION SERVICES LISTING FOR WIC AGENCIES, HOSPITALS, CLINICS ONLYHays.4102010-01-19T18:43:00Z2010-01-19T19:00:00Z382146853910549611.0000APPLICATION FOR BREASTFEEDING RESOURCE DIRECTORY INSTITUTIONAL PROVIDER OF LACTATION SERVICES LISTING FOR WIC AGENCIES, HOSPITALS, CLINICS ONLY. If your lactation services are free or reimbursed through Medi-Cal, your listing will be free of charge. If there is a fee for any of your institution’s services, we charge a listing fee of $100 ($200 if hyperlink to web address is required). This year, you may either:Fill out this form electronically, save it to your computer, and e-mail it (along with credit card information, if fees apply) to louisetlan@earthlink.net. OR you may print the application, fill it out, and then mail or fax the application (along with credit card information or check, if fees apply) to:Louise Arce Tellalian1911 San Ysidro DriveBeverly Hills, CA 90210-1520310-274-2272; Fax 310-859-7077APPLICATIONS MUST BE RECEIVED NO LATER THAN FEBRUARY 1, 2010 FOR INCLUSION IN THE 2010 WEB DIRECTORY. FILL OUT INSTITUTIONAL LISTING FORM AS WELL.Contact Information: (This information is for office use only and will not be published.)Name: /////wAAAAAUAAUAVABlAHgAdAAxAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA FORMTEXT      Mailing Address://///wAAAAAUAAUAVABlAHgAdAAyAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA FORMTEXT      City: /////wAAAAAUAAUAVABlAHgAdAAzAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA FORMTEXT      State: /////wAAAAAUAAUAVABlAHgAdAA0AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA FORMTEXT      Zip Code +4: /////wAAAAAUAAUAVABlAHgAdAA1AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA FORMTEXT      Official contact person(s) & title: /////wAAAAAUAAYAVABlAHgAdAA1ADAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT      Phone: ( /////wAAAwAAAAUAVABlAHgAdAA2AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA FORMTEXT     ) /////wAAAwAAAAUAVABlAHgAdAA3AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA FORMTEXT    -/////wAABAAAAAYAVABlAHgAdAA1ADEAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT      Ext./////wAAAAAUAAUAVABlAHgAdAA4AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA FORMTEXT      Hours://///wAAAAAUAAUAVABlAHgAdAA5AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA FORMTEXT      Fax: ( /////wAAAwAAAAYAVABlAHgAdAAxADAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT     ) /////wAAAwAAAAUAVABlAHgAdAA3AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA FORMTEXT    -/////wAABAAAAAYAVABlAHgAdAA1ADEAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT     e-mail address: /////wAAAAAUAAYAVABlAHgAdAAxADIAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT      @/////wAAAAAUAAYAVABlAHgAdAAxADMAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT      Professional License/Registration Number: M.D. /////2UAAAAUAAYAQwBoAGUAYwBrADQAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA FORMCHECKBOX R.N./////2UAAAAUAAYAQwBoAGUAYwBrADUAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA FORMCHECKBOX L.V.N/////2UAAAAUAAYAQwBoAGUAYwBrADYAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA FORMCHECKBOX R.D./////2UAAAAUAAYAQwBoAGUAYwBrADcAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA FORMCHECKBOX OTR/////2UAAAAUAAYAQwBoAGUAYwBrADgAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA FORMCHECKBOX PTR/////2UAAAAUAAYAQwBoAGUAYwBrADkAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA FORMCHECKBOX Other /////2UAAAAUAAYAQwBoAGUAYwBrADMAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA FORMCHECKBOX Please Describe: /////wAAAAAUAAYAVABlAHgAdAAxADkAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT      Professional License/Registration Number: /////wAAAAAUAAYAVABlAHgAdAAxADQAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT      Expiration: /////wAAAAAUAAYAVABlAHgAdAAxADUAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT      Lactation Certification: List type of certification(s) as written on your certificate, e.g. "certified lactation educator", certifying agency, date certificate was issued, and expiration date if applicable.Type of certification: /////wAAHwAAAAYAVABlAHgAdAAxADYAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT       Certifying agency: /////wAAAAAUAAYAVABlAHgAdAAxADcAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT      Date issued: /////wAAAAAUAAYAVABlAHgAdAAxADgAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT      Expiration date if applicable: /////wAAAAAUAAYAVABlAHgAdAAxADkAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT      I VERIFY THAT ALL INFORMATION ON MY APPLICATION IS TRUE AND ACCURATE Name of coordinator: /////wAAAAAUAAYAVABlAHgAdAAyADAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT      Date: /////wAAAAAUAAYAVABlAHgAdAAyADEAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT      PLEASE FILL OUT INSTITUTIONAL LISTING FORM THAT FOLLOWS AS WELL.HOW WOULD YOU LIKE YOUR INSTITUTION TO BE LISTED IN THE DIRECTORY?Example: XYZ Medical Center 818-555-1212Jane Smith, RN, CLC, Director - Breastfeeding Clinic, MWF mornings000 Center Street, 2nd Floor, Los Angeles 91000Breastfeeding classes, prenatal, post partum, support groups; consults inhospital, clinic; breast pump rentals; weekend coverage; low cost services.Eastside WIC 888-555-1212Maria Arroyo, RD, CLE, Coordinator000 E. Main Street, Los Angeles 9000010 sites throughout eastern Los AngelesConsults in hospital, WIC Centers; toll free hotline; breast pump loan program for hospitalized infants; peer counselors; Spanish spokenName of agency: /////wAAAAAUAAYAVABlAHgAdAAyADIAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT      Name and credentials of contact person: /////wAAAAAUAAYAVABlAHgAdAAyADMAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT      Street address: /////wAAAAAUAAYAVABlAHgAdAAyADQAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT      City: /////wAAAAAUAAYAVABlAHgAdAAyADUAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT      State: /////wAAAgAAAAYAVABlAHgAdAAyADYAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT   Zip code + 4: /////wAABQAAAAYAVABlAHgAdAAyADcAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT      -/////wAABAAAAAYAVABlAHgAdAAyADgAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT     Geographic Service area(s) /////wAAAAAUAAYAVABlAHgAdAAzADcAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT      Contact Phone: (/////wAAAwAAAAYAVABlAHgAdAAyADkAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT     ) /////wAAAwAAAAYAVABlAHgAdAAzADAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT    -/////wAABAAAAAYAVABlAHgAdAA1ADIAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT     Ext. /////wAAAAAUAAYAVABlAHgAdAAzADEAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT       Hours: /////wAAAAAUAAYAVABlAHgAdAAzADIAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT      Services offered: Keep my listing the same as last year /////2UAAAAUAAcAQwBoAGUAYwBrADMANwAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMCHECKBOX OR check all that apply below:Breastfeeding classes: Prenatal /////2UAAAAUAAYAQwBoAGUAYwBrADEAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA FORMCHECKBOX Post partum /////2UAAAAUAAYAQwBoAGUAYwBrADIAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA FORMCHECKBOX Other /////2UAAAAUAAYAQwBoAGUAYwBrADMAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA FORMCHECKBOX /////wAAAAAUAAYAVABlAHgAdAAzADMAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT      Consults: In client's home /////2UAAAAUAAYAQwBoAGUAYwBrADQAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA FORMCHECKBOX In hospital /////2UAAAAUAAYAQwBoAGUAYwBrADUAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA FORMCHECKBOX In clinic /////2UAAAAUAAYAQwBoAGUAYwBrADYAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA FORMCHECKBOX Weekends /////2UAAAAUAAYAQwBoAGUAYwBrADcAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA FORMCHECKBOX Breast pumps: Purchase /////2UAAAAUAAYAQwBoAGUAYwBrADgAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA FORMCHECKBOX Rentals /////2UAAAAUAAYAQwBoAGUAYwBrADkAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA FORMCHECKBOX Loans /////2UAAAAUAAcAQwBoAGUAYwBrADEAMAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMCHECKBOX Related sales /////2UAAAAUAAcAQwBoAGUAYwBrADEAMQAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMCHECKBOX Do you provide free or Medi-Cal reimbursable services? /////2UAAAAUAAcAQwBoAGUAYwBrADMAMAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMCHECKBOX In what languages are services provided? /////wAAAAAUAAYAVABlAHgAdAA0ADEAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT      Special services (teens, support groups, hearing impaired, etc.) /////wAAAAAUAAYAVABlAHgAdAAzADYAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT      If you would like to add something unique, describe here: /////wAAAAAUAAYAVABlAHgAdAA0ADYAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT      Check your listing to be sure it is no longer than 6 lines, 80 characters /spaces per lineIf fees apply, how and when will payment be made? /////wAAAAAUAAYAVABlAHgAdAA0ADYAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT      DID YOU FILL OUT INSTITUTIONAL APPLICATION FORM? FILL OUT QUESTIONNAIRE AND MAIL WITH APPLICATION.PLEASE SUBMIT THE FOLLOWING QUESTIONNAIRE TO:Louise Arce Tellalian1911 San Ysidro DriveBeverly Hills, CA 90210-1520310-274-2272; Fax 310-859-70771. Your Agency name /////wAAAAAUAAYAVABlAHgAdAAzADgAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT      2. Do you wish to be kept on Directory application mailing list? Yes /////2UAAAAUAAcAQwBoAGUAYwBrADEAMgAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMCHECKBOX No /////2UAAAAUAAcAQwBoAGUAYwBrADEAMwAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMCHECKBOX 3. Are you listing yourself as a lactation provider for 2010? Yes /////2UAAAAUAAcAQwBoAGUAYwBrADEANAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMCHECKBOX No /////2UAAAAUAAcAQwBoAGUAYwBrADEANQAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMCHECKBOX Reason /////wAAAAAUAAYAVABlAHgAdAAzADkAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT      4. Do you know of any other lactation professional that would be interested in receiving this mailing? If so, please provide:Name: /////wAAAAAUAAYAVABlAHgAdAA0ADAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT       Mailing address: /////wAAAAAUAAYAVABlAHgAdAA0ADEAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT      City: /////wAAAAAUAAYAVABlAHgAdAA0ADIAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT      State: /////wAAAgAAAAYAVABlAHgAdAA0ADMAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT    Zip code+4: /////wAABQAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT      -/////wAABAAAAAYAVABlAHgAdAA0ADUAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT     Phone number: (/////wAAAwAAAAYAVABlAHgAdAAyADkAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT     ) /////wAAAwAAAAYAVABlAHgAdAAzADAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT    -/////wAABAAAAAYAVABlAHgAdAA1ADIAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT     E-mail Address: /////wAAAAAUAAYAVABlAHgAdAA0ADgAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT      @/////wAAAAAUAAYAVABlAHgAdAA0ADkAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA= FORMTEXT      Breastfeeding Task Force of Greater Los Angele s Breastfeeding Resource Directory - 2010 Institutional Application