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High 5 for Mom & Baby Application & Renewal Form

Kansas Hospitals and Birth Centers:

Please use this online form to apply for your annual renewal (self-assessment) of High 5 for Mom & Baby recognition. Facilities following all ten of the High 5 practices will receive High 5 for Mom & Baby Premier recognition at renewal.

Facilities new to High 5 for Mom & Baby can use this form to apply for initial recognition.

To preview the forms (pdf) before completing online you may view the annual renewal (self-assessment) form here or the initial application form here.

If you have questions about High 5 for Mom & Baby or the application process, please contact program coordinator Cara Gerhardt at coordinator@high5kansas.org. 

Thank you for your commitment to helping ensure successful breastfeeding for moms and babies!

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