MBFPC Training Request Form

Persatuan Pembimbing Ibu Menyusu Malaysia
Malaysian Breastfeeding Peer Counsellor Association

Email : training@malaysianbfpc.com

Website : www.malaysianbfpc.org
MBfPC Entry Level Training Request Form

Thank you for your interest in our training course. Upon submitting this form, your name will be listed in the waiting list. We will email you the information of next available training and invitation to register (based on your preferred location).
Section A : Personal Details
1. Full name*
2. I.C No.*
3. Mailing Address*
Postcode*
Town :*
State*
6. Mobile no.*

Codetelephone no.
Telephone no. :

Area codetelephone no.
7. Personal E-mail address :*
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)SabahSarawakWilling to travel to other location
Section B : Breastfeeding Experience
11. Do you have any breastfeeding experience ?*

NoYesNo, my wife did :)

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

13. Are you currently breastfeeding your child ?*

YesNo
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 Entry Level Training Request Form