Community Bridges WIC Program Interest Form
* Required
Date
*
MM slash DD slash YYYY
First Name
*
Last Name
*
Street Address
*
City
*
State
*
ZIP Code
*
Primary Number
*
Is this a cell phone?
Yes
No
Preferred Language
*
Please select one:
English
Spanish
Other
List your preferred language
Select only one even if more than one answer applies to you.
*
I am pregnant
I gave birth in the last 6 months
I am breastfeeding a child up to one year old
I am applying for a child/children under the age of 5
I have or my child has Medical
*
Yes
No
Have you ever had WIC before for a previous pregnancy or a child?
*
Yes
No
Preferred Time of Contact
*
Please select one:
8am – 12pm
1pm – 6pm
CAPTCHA
Click the SEND button only once. It may take a few seconds for the form to be submitted. You will see a confirmation message when the form has been received.
Comments
This field is for validation purposes and should be left unchanged.
