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Formulario de pre-solicitud WIC
Formulario de pre-solicitud WIC
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Para empezar, rellena el siguiente formulario.
WIC Pre-Application Form
Name
*
Name
Applicant's Information
Applicant's Information
Name
Applicant's Address
*
Applicant's Address
Applicant's Address
Applicant's Address
City
City
State/Province
State/Province
Zip/Postal
Zip/Postal
Country
Afghanistan
Aland Islands
Albania
Algeria
American Samoa
Andorra
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Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
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Grenada
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Guinea-Bissau
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Indonesia
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Isle of Man
Israel
Italy
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Japan
Jersey
Jordan
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Laos
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Liberia
Libya
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Madagascar
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Malaysia
Maldives
Mali
Malta
Marshall Islands
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Mauritius
Mayotte
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Monaco
Mongolia
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Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
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Nigeria
Niue
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Norway
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Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
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Samoa
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Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
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Singapore
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Slovenia
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Applicant's Email
Applicant's Phone
*
Other Phone (Optional)
Applicant's Date of Birth
Mother's Status
*
Pregnant
Post-partum
Do you have infants or children under the age of 5? *
*
Yes
No
Do You Need Additional Help?
Yes, please share my info
No, don't share my info
We all know that babies don’t come with directions. Could you use the help and support of your own free personal nurse or case manager? Are you in need of help with housing issues or income support? Does your infant have a safe place to sleep? Are you interested in hearing about free classes for new moms and families? The Foundation for Delaware County offers free personal case managers or nurses for pregnant women and new parents. They can help you to connect to community resources and provide parenting education and ongoing support until your child turns 18 months or two years old. "By clicking below, I do/do not give the Foundation for Delaware County WIC Program permission to share my contact information with the Foundation’s Healthy Start and/or Nurse-Family Partnership. I understand that a nurse or case manager will contact me via telephone or email soon to share more information and see if Healthy Start or Nurse-Family Partnership is a good fit for me and my baby."
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