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WIC Appointment Request

  1. To request an appointment with WIC, please complete the form below:

  2. Personal Information

  3. My mailing address is the same as my home address.*

  4. Family Information

  5. Do you have children under the age of 5?*

  6. Foster Child?

  7. Foster Child?

  8. Foster Child?

  9. Foster Child?

  10. Are you pregnant?*

  11. Appointment Information

  12. When would you like an appointment?*

  13. Check all of days/times you could make an appointment:

  14. Send Your Appointment Request

  15. Click the Submit button below to send your appointment request. A member of our staff will review your information, check available times, and then contact you by email or phone to schedule your appointment. If you would like a copy of this request sent to you, please enter an email address below.

  16. Leave This Blank:

  17. This field is not part of the form submission.