Name(Required) First Last Preferred PronounsAddress(Required) Street Address Address Line 2 City County / State / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Mobile Number(Required)Email address(Required) Date of Birth About your LCGB membershipWhat year did you join LCGB? Do you have/had a role within the organisation? Have you used any of the member benefits for your lactation education? (e.g. text books, GOLD or iLactation conferences, LCGB conference, Health E Learning etc) Please specify: How did you first learn about this grant? Some questions about your workWhich organisation/NHS trust do you work/volunteer with? What is your current role in supporting breastfeeding families? Where is most of your breastfeeding work carried out? Please give names of any hospital, city, wards, etc. What percentage of your time supporting breastfeeding is spent in paid roles? What percentage of your time supporting breastfeeding is spent in voluntary roles? Some questions about your IBCLC journeyAt what stage are you towards completing all the required elements before applications open to take the examination? Please use either the free form box below or the check boxes further downStatus of readiness for IBLCE application 14 x Health Sciences modules completed 14 x Health Sciences modules still to complete Health sciences not applicable as am a Health Care Professional Practice hours completed Practice hours still to complete Specific lactation education completed Specific lactation education still to complete How would becoming an IBCLC benefit you in your work?How would becoming an IBCLC benefit you on a personal level?How would becoming an IBCLC benefit the families you support?How would becoming an IBCLC fit with the organisation you are currently practising in?What are your plans for practising as an IBCLC?Any other relevant information to support your applicationSome questions about youWhat languages do you speak and/or write in addition to English, including BSL? (Please identify spoken and/or written)Are you, or your household, claiming any UK Welfare Benefits? Yes No What is your annual household disposable income (ie income after tax & NI deductions) £20 000 or below ¨ £25 000 or below ¨ £30 000 or below ¨ £40 000 or below Are you a registered Carer? Yes No Prefer not to say Do have a disability or health condition? Yes No How do you describe your ethnicity?Do you self-describe as LGBTQIA+? Yes No Prefer not to say RefereePlease provide a referee for your application, this can be someone you work with or know who we can talk to regarding your application. The Referee will be contacted after the phase 2 interview, preferably by telephone.Referee Full Name(Required)Referee Phone Number(Required)Referee Email Address(Required)ConsentPlease confirm the following statements:(Required) I agree to the terms outlined in this application form and Grant information page By submitting this form I am giving permission for the Sally Brooks Grant Team to make further enquiries and/or request my attendance in a telephone/ Zoom interview in relation to this application If selected as a recipient, I understand and agree that my name may be publicised in the LCGB Newsletter and website, along with a brief story/profile I declare that the information provided is true and correct Type name in full here to confirm you agree to the terms above(Required)Consent(Required) I agree to being contacted by LCGB for this Grant application
