Maternity Facility Name: Click here to enter text.
Maternity Facility Address: Click here to enter text.
Address Line 1: Click here to enter text.
Address Line 2: Click here to enter text.
City: Click here to enter text.
Parish: Click here to enter text.
Zip Code: Click here to enter text.
Primary Contact Person Information:
First: Click here to enter text.
Title: Click here to enter text.
Last: Click here to enter text.
Best Phone Number: Click here to enter text.
Email address: Click here to enter text.
In order to earn recognition as a Bag Free Facility, maternity facilities must demonstrate that:
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No commercial infant formula gift bags are distributed. Note that removing formula from commercial bags before distribution does not suffice.
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All gifts to maternity patients are free of infant formula advertising of all varieties (coupons, samples, infant feeding information published by a formula company, etc.)
In order to be recognized as a Bag Free Champion, maternity facilities must demonstrate that:

No commercial infant formula gift bags are distributed. Note that removing formula from commercial bags before distribution does not suffice.
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All gifts to maternity patients are free of infant formula advertising of all varieties (coupons, samples, infant feeding information published by a formula company, etc.)
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No commercial infant formula gift bags or promotional items are distributed to mothers of infants in the NICU or special care nursery.
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A 24-hour or less supply of infant formula is given at discharge ONLY if it is left over formula from the baby’s cart and/or is medically indicated by the infant’s health care provider.
Last rev. 7/20/2015

Please enter your initials ONLY for the practices/policies that your facility adheres to.
By entering my initials here, I certify that this facility does NOT distribute commercial infant formula advertising, including bags manufactured by formula companies (with or without their labels), coupons, magazines or samples. Click here to enter text.
By entering my initials here, I certify that this facility does NOT distribute infant formula gift bags to mothers of infants in the NICU or special care nursery. Click here to enter text.
By entering my initials here, I certify that this facility does NOT routinely discharge patients with infant formula. (In rare cases of medical and financial necessity, the facility may provide maternity patients with a 24-hour or less supply of infant formula.) Click here to enter text.
Does your management team need additional help with learning how to eliminate infant formula marketing? What can we do to help? Click here to enter text.
How would you like to celebrate your award? (Check all that apply)
☐ Have a LBC representative present the award in-person.
☐ Receive the award via email.
☐ Receive the award in the mail.
☐ Have our facility name added to the LBC listing of Bag Free Facility/Bag Free Champion recipients.
☐ Have our facility name added to the national listing, Banthebags.org.
☐ Other, please specify: Click here to enter text.
Please return your application to Marci Brewer at Marci.Brewer@la.gov
.
Last rev. 7/20/2015