WIC Appointment Request Form
For appointments at the WIC located at 400 N. Highland Avenue in Aurora, IL only.
Please note:
Requests sent on a Friday or on the Weekend may not receive a response until the following business week.
Your First and Last Name
First Name
Last Name
Contact Number
Please enter a valid phone number.
Email Address
example@example.com
What is your preferred language?
English
Spanish
Other Language
If other, please write in your preferred language.
Do any of the following describe you?
I am pregnant
I have a child/children under 5 years old.
I have a baby/babies under 1 year old.
Have you received benefits from WIC before?
Please Select
Yes
No
Not Sure
Do you have any questions or concerns or important information to share with us?
Submit
Should be Empty: