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First Name

Last Name

Stony Brook Email Account

Please note that this is the account we will use to communicate to you about anything related to this request and/or your access to said spaces.

Stony Brook ID Number

Stony Brook ID *PROX* Number
Your prox number is located on the back of your Stony Brook ID (printed upside down and underneath the logos.) Typically this number is 6 digits long. This is required in order to give you card access to of of the spaces that are 'online' at time of request.

Campus Affiliation
Check all that apply.

Student

Staff

Faculty

Affiliate

Volunteer

Other

Please confirm that you are actively breastfeeding and intend to use this space for lactation-specific purposes.

I confirm the above statement.
I am seeking guest access for lactation-specific purposes. (Please expect a follow-up email for more information.)
I can NOT confirm he above statement.

The CEWIT/R&D Park lactation room is only designated for this use by special request. Do you require access to this space?
To view a map of this building's location, click here.

No
Yes

Please indicate an how frequently you expect to use the CEWIT/R&D Park lactation room.
This estimation is for coordination purposes only.

I expect this space to be my primary lactation room.
I expect to use this space a few times a week.
I expect to use this space occasionally throughout the month.
I expect to use this space less than the abovementioned options.

Please note that access is intended exclusively for actively breastfeeding parents. If you have questions about access, please contact the Department of Student Community Development at student_community_development@stonybrook.edu.

How/from whom did you hear about this campus resource?