Participant - Tell WIC About Completed Nutrition Education Classes

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Participant Information

First Name

Last Name

Phone

Date of Birth

Please enter DOB in this format mm/dd/yyyy

WIC Family ID (8 digits)

Preferred Language

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Class Information

Education Type Please select... Online Class Self Paced Lesson Other Education Source Ex: Baby Dental, Headstart File Attachment Please provide a picture of the class certificate of completion.

Class/Lesson Name

Class/Lesson Completion Date

What did you Learn?

What did you learn? What do you plan on doing differently after taking the class?

Questions?

Do you have any questions about what you learned?

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