Form

Persatuan Pembimbing Ibu Menyusu Malaysia
Malaysian Breastfeeding Peer Counsellor Association

Email : training@malaysianbfpc.com

Website : www.malaysianbfpc.org
MBfPC Training Request Form
Section A : Personal Details
1. Full name *
2. I.C No. *
3. Mailing Address *
Postcode *
Town : *
State *
6. Mobile no. *

- Code telephone no.
Telephone no. :

- Area code telephone no.
7. E-mail : *
Website (if any)
8. Facebook ID:
Facebook Url :
9. Occupation : *
Position :
Employer :
10. Preferable Training Location : *

Northern Region (Perlis, Penang, Kedah & Perak) Central Region (Selangor, Kuala Lumpur & Putrajaya) Southern Region (Negeri Sembilan, Malacca & Johor) East Coast Region (Pahang, Terengganu & Kelantan) Sabah Sarawak Willing to travel to other location
Section B : Breastfeeding Experience
11. Do you have any breastfeeding experience ? *

No Yes No, my wife did :)

12. How long did you breastfeed your child(ren) ?

13. Are you currently breastfeeding your child ? *

Yes No
14. If yes, how old is your child now ?
15. Why do you want to be trained as a Malaysian Breastfeeding Peer Counselor ? *
Nyatakan sebab anda ingin dilatih sebagai Pembimbing Ibu Menyusu Malaysia.
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MBfPC Training Request Form