Buddy Program Enrollment Form
Interested in joining the WIC Breastfeeding Buddy Program? Fill out the form below to get started
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1.
Participant name (first and last)
(Required.)
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2.
Participant birth date
(Required.)
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3.
Infant birth date or Estimate delivery date
(Required.)
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4.
Phone number
(Required.)
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5.
Email address
(Required.)
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6.
Mailing address (street, city, state, zip code)
(Required.)
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7.
Please select the clinic you visit for WIC Program services
(Required.)
Barrow County Health Department
Clarke County WIC Office
Elbert County Health Department
Greene County Health Department
Jackson County Health Department- Commerce
Jackson County Health Department- Jefferson
Madison County Health Department
Morgan County Health Department
Oconee County Health Department
Oglethorpe County Health Department
Walton County Health Department- Monroe
Loganville Health Department
I do not receive WIC services