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2. 
3. 
5. Name*
6. Date of Birth*
8. Gender
9. Race/Ethnicity
11. Address*
13. City*
14. State*
15. Zip Code*
17. Phone Number*
18. Email
20. When is the best time to reach you?
22. When are you due/When was the baby born?
24. When did you start to receive prenatal care (please check one)

    1. 0-12 Weeks

    1. 13-24 Weeks

    1. 25-40 Weeks
26. Who is your medical provider?
27. Who is your child's medical provider?
29. How are you feeding/planning to feed your baby?

    1. Breast

    1. Formula

    1. Both

    1. Unsure
31. How many children are in your home?
33. What support systems do you have right now (check all that apply)

    1. Partner
    2. Spouse

    1. Parent(s)
    2. Grandparent(s)

    1. Friend(s)
    2. Community Services

    1. Other
35. Which Services do you receive now (check all that apply)

    1. WIC
    2. SNAP

    1. TANF
    2. HUD

    1. HEAP
    2. SSI/SSD

    1. Medicaid
    2. Family/Child Health Plus

37. My signature gives the Wyoming County Health Department permission to contact me by email, phone, text, and/or mail to share information with me about the program.

39. Signature
40. Date
Leave This Blank:


42. 1. Receive an email copy of this form.
43. Email address

    This field is not part of the form submission.

44. Submit

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