Community Bridges WIC Program Interest Form

* Required

The Community Bridges WIC Program offers services to families in Santa Cruz County and surrounding communities. If you reside outside of these areas, please visit the WIC California directory to find the nearest office: myfamily.wic.ca.gov/Home/WICOfficeGrocer

Date*

MM slash DD slash YYYY

First Name*

Last Name*

Street Address*

City*

State*

ZIP Code*

Primary Number*

Is this a cell phone?

Yes

Preferred Language*

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

Have you ever had WIC before for a previous pregnancy or a child?*

Yes

Preferred Time of Contact*

CAPTCHA

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Name

This field is for validation purposes and should be left unchanged.