WIC Interest Form - JEFFERSON FRANKLIN COMMUNITY ACTION CORPORATION

Jefferson Franklin Community Action Corporation

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WIC Interest Form

Please fill out the following questions to the best of your ability. This form does not automatically enroll you, it provides the WIC agency with information to contact you for enrollment. It's that easy! Current and former participants should contact their WIC agency to complete recertification.

* Indicates required field

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Race *

Ethnicity *

Hispanic or Latino Non Hispanic or Latino

Sex *

Male Female

Please tell us about yourself and your family. Select all that apply. *

I am/We are pregnant. I am/We are a new parent. I/We have a child or children under 5 years old. I am/We are a foster parent or legal guardian of a child or children under 5 years old. I/We had a pregnacy loss that was less than 6 months ago. I am/We are a breastfeeding mother of a child under the age of 1.

Do you have a preferred WIC clinic you would like to hear from? *

Hillsboro Arnold Unsure/No preference

Tell us about the children for whom you are applying for:

How many children in your household need WIC benefits? *

Please tell us the ages of the children for whom you are applying: *

Infant - under 1 year old One (1) year old Two (2) year old Three (3) year old Four (4) years old

Please tell us the biological sex of the child for whom you are applying: *

Male Female

I would like to be contacted by: *

Phone Phone or Email

Email *

Primary Phone Number *

Type: *

Home Phone Cell Phone Work Phone

Optional Secondary Phone Number *

Type: *

Home Phone Cell Phone Work Phone

May we leave a message if no one answers the phone call? *

Yes No

Does the Missouri WIC program have permission to text you about your potential eligibility? *

Yes No

What are the best days of the week for an appointment? *

Monday Tuesday Wednesday Thursday Friday Any Day

What are the best times of the day for an appointment? *

Morning Afternoon Early Evening Any Time

How did you hear about WIC? *

Have you ever been enrolled in WIC before? *

Yes No

What questions can we answer for you? (optional) *

Submit

JEFFERSON FRANKLIN COMMUNITY ACTION CORPORATION
#2 MERCHANT DRIVE P.O. BOX 920, HILLSBORO MO 63050
PHONE: 636-789-2686
RELAY MISSOURI TTY SERVICE 1-800-735-2966/ 1-800-735-2466
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