Breastfeeding Equipment User Agreement Template - Wic Program, Kansas Department Of Health And Environment


I understand that I am being provided with a [type of pump] ____________________________________because:
The proper use and cleaning of the above breastpump has been explained to me and I fully understand the instructions.
The proper usage and storage of pumped breastmilk has also been explained to me and I have been given written
guidelines to follow. WIC staff has shown me how to set up and clean the pump.
I understand and agree that this service is provided by [Name of WIC clinic]____________________________________
to promote and support breastfeeding and that this WIC agency is not a dealer in this type of product.
I understand this local WIC Clinic will be contacting me on a regular basis regarding use of this pump. I understand it is
my responsibility to return clinic phone calls and update the clinic regarding the use of this pump. If regular phone
contact is not maintained, the agency may request the pump be returned. Failure to return the pump within 60 days of a
return request may result in recovery of costs.
If I have received a multi-user electric breastpump, I understand that I must return the pump in clean and good
condition and undamaged to the WIC clinic by the agreed to Return By Date of___________________ or within 7
working days after I am notified that I must return the pump. I shall return the multi-user electric pump when one of
the following conditions is met.
1) There is no continued need for the pump as determined by myself or a staff member.
2) I stop breastfeeding my baby.
3) I stop participating in the [name of WIC clinic] ___________________________________WIC Program.
4) The WIC agency requests that I return the pump.
5) My certification as a WIC breastfeeding client is terminated.
6) I plan to transfer to another WIC Clinic (check with your local WIC clinic).
I understand that if I do not return the pump or return it damaged, I may be subject to a financial penalty equal to the
value of the pump.
If I have received a single-user electric breastpump, I understand that this equipment is for my use only, is now my
property, and shall not be loaned or sold to any other person.
I further agree not to bring any claim against the [name of clinic]___________________ WIC Program, Kansas
Department of Health and Environment, or any official, employee, or agency connected with this program for any
damages or expenses arising from the use of the above named breastfeeding equipment provided.
I have read the above before signing, understand the contents, and will receive a copy of this agreement.
Client Name _______________________________________________
Client ID Number ___________________________________________
Client telephone numbers ___________________________________
Additional client work or cell phone numbers _________________________________________________
Email Address _______________________________________________
Relative/ Friend name and phone number _____________________________________________________________
Client Signature _____________________________________________________________
Staff issuer name
Name of Clinic
Clinic Address
Clinic Phone Number


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