WIC Request Form
WIC Request Form
Name
Name
*
First
Last
County
*
County
Barry
Eaton
Other
Other
Phone
Phone
*
-
###
-
###
####
Email
Reason(s) for Inquiry:
*
Reason(s) for Inquiry:
Do I qualify?
Food Packages
Breastfeeding Support
Healthcare Provider Referrals
Nutrition Counseling/Education
Immunizations
Other
Other
Select ALL options you are needing additional information on.