2025 Twin Tiers Breastfeeding Network ANNUAL BREASTFEEDING FRIENDLY AWARDS For Education and Support

Annual Breastfeeding Awards for Education and Support

2025 NOMINATION FORM
Nominations are accepted throughout the year via:
- email: shicks@chemungcountyny.gov
- call: (607) 873-1282
- fax: (607) 737-3576
If you would like to nominate more than one person or organization, please complete a seperate form for each.

Please provide as much information as possible, thank you!
I would like to nominate:*

An individualAn organization (workplace, business, public space, school, etc.)
Place of Business*
Contact Person*

First NameLast Name
Name of Individual*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email
example@example.com
The nominee (Check all that apply):

provides breastfeeding education and/or support in the communityhas a written policy that supports breastfeedingprovides clean and comfortable place where I can pump or store my milkprovides sufficient time for pumping or breastfeeding my babyhas onsite daycare facilities where I can bring my baby to workprovides supportive and friendly environment where I feel free to breastfeed my babyhas signs and directions to the "Baby Friendly" or "Lactation" areasprovides a supportive and friendly environment where I feel free to breastfeed my babydonates breastmilk to the New York Milk Bank or through informal sharingOther
Any other details you would like us to know about the candidate and why you nominated them (optional):
Your Name (In case we have any questions)*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email
example@example.com
I heard about this from (please check all that apply):

WICFacebookWorkFriendOther
For further information please contact:

Samantha Hicks at shicks@chemungcountyny.gov or (607) 873-1282
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Annual Breastfeeding Awards for Education and Support