EFNEP Enrollment Form WIC (Women, Infants and Children) April 2022
 
Sign in to Google to save your progress. Learn more
Email *
Phone number *
First Name: *
Last Name: *
How old are you? *
Are you Pregnant? *
Are you breast feeding? *
What is your highest educational level? *
Gender *
How many children do you have? *
How old are your child
Race
Clear selection
Ethnicity
Clear selection
How many people live in your household? *
What is your household income ($/month)? *
Which WIC agency do you receive WIC benefits from? *
Which public assistance programs are you and/or your family currently receiving *
Required
What days and times of the week are best for you to attend workshops?
Afternoons ( between 2 pm- 5pm)
Evening (between 6pm-8pm
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Who will be attending EFNEP workshops? *
Required
Address
The EFNEP program will mail incentives and certificates to your house
Street Address
Zip
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms