Lactation Room Usage and Participation Agreement

I have received and reviewed the Samuel Merritt University Lactation Room Guidelines and the Lactation Room Rules and have had an opportunity to ask questions and have had all of them answered to my satisfaction.

I agree to abide by the rules for reserving and using the Lactation Room. 

I understand that I am responsible for maintaining the cleanliness of the Lactation Room, its furnishings and the refrigerator, and I agree not to leave personal items or equipment in the room.

I am aware that Samuel Merritt University does not provide ice packs, containers or other accessories; therefore, it is my responsibility to furnish these items.

I understand that Samuel Merritt University is not responsible for the integrity or security of breast milk stored in the Lactation Room refrigerator, any other refrigerator on the University campus, or my personal cooler.  I am aware that staff will dispose of milk stored for more than 24 hours in the Lactation Room refrigerator.

 

months
(date)

 

 

By clicking submit, you agree to abide by this agreement.

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