EFNEP Enrollment Form - WIC (Women, Infants and Children) - Spring 2024
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Email *
First Name: *
Last Name: *
Gender *
Phone number *
How old are you? *
Are you Pregnant? *
Are you breast feeding? *
What is your highest educational level? *
How many children do you have? *
How old are your child
Race
Clear selection
Ethnicity
Clear selection
Ethnic Group/Nationality
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
Do you prefer in-person or virtual classes?
Clear selection
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 (number, street, city, state)
Zip code
Submit
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