2. Are you currently in the Clay County WIC program? Were you previously in the WIC program?

   We would love to hear your story! If you are willing to share about your experience in WIC, please complete the form below. 

   You may be contacted to share your story and help us inform other eligible families in Clay County about the services WIC provides and how it can help improve the health of their own family.

4. First Name*
5. Last Name*
7. Zip Code of Residence*
8. City of Residence
10. Phone Number*
12. Email Address
16. What role do/did you play?
    -- Select One --MotherFatherGrandparentFoster parentOther
17. Currently in WIC?
    -- Select One --I am currently in WICI used to be in WIC
19. At what stages are/were you in the WIC program? Check all that apply.

    1. Breastfeeding
    2. Prenatal/Pregnancy
    3. Postpartum
    4. Child(ren) Newborn to 1
    5. Child(ren) Ages 1-5
21. Please write a short description of your time in the WIC program.

    Examples of things you could mention:

    • What WIC services have been most helpful to your family? 
    • Why has WIC been helpful for your family? 
    • What is something about WIC that you think everyone should know?
23. I consent to be contacted by Clay County Public Health Center about my WIC experience.*

    1. Agree
    2. Disagree
Leave This Blank:


25. Submit

* indicates a required field