ELCA Lactation Consultant Application Form

PERSONAL INFORMATION:

Name:*

Email Address:*

Phone Number:*

Residence:*

PROFESSIONAL QUALIFICATIONS:

Primary Specialty:*

Mention Specialty:

Academic / Professional Degree:*

Other Qualification:

IBCLC ID Card Number:*

Your Initial IBCLC certification was in:*

Did you Recertify since your Initial Certification?*

EXPERIENCE & SKILLS:

Years of Experience in Lactation Consultation?*

Have you previously worked in a lactation clinic?*

Please specify the locations and describe your experience?

Do you have additional training certificates or advanced courses in lactation?*

Please list them?

In your opinion, what are the top 3 essential skills a successful lactation consultant must possess?

Do you agree to attend a personal interview if requested?*