1.I will breastfeed for ___________.

2.I will begin breastfeeding as soon as possible after the delivery of my baby_____yes.

3.I will not use a bottle for ________.

4.I will not use a pacifier for ________.

5.I will not give my baby any other liquids or foods other than breast milk for________.

6.I will have my baby in the hospital room with me if possible _____yes.

7.At home, my baby will sleep in the same room with me for _______.

8.I will ask a nurse to help and watch me in breastfeeding at least twice beforeleaving the hospital.

9.I will ask for a lactation consultant at the hospital if I experience ANYproblems or have ANY concerns about breastfeeding.

10.I will contact my local LLL leader and/or group, ___________________, withinone week of giving birth _____yes.

11.I will schedule an appointment with my baby’s doctor at ______ days afterbirth.

12.I will commit to the trying to breastfeed exclusively for at least  _______.

13.If I think I need to stop breastfeeding I will first talk with______________________ for advice.

Mother’sName: _________________ Signature: ___________________

Date:_______

MainSupport Person: _________________ Signature: ___________________ Date:_______