Form Center Module

Form Center

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WIC Shopping Feedback or Request for Assistance

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  2. This form can be used to provide feedback about a shopping experience while using WIC benefits. It can also be used to request a phone call from WIC Staff for additional help.
  4. WIC_logo_green_transparent
  6. Your Information and City of Residence.
  21. Grocery Store Information
  24. Grocery store receipts can provide helpful information.
  28. The system will allow one image to be uploaded of a product you thought should have been allowed with your WIC benefits. Send images of the product and the bar code located on the item. You may email additional images with your name to wic@tchd.org.
  30. Note: Please be aware this form is not a secure method of communication. Please do not include information in this form you would like to remain confidential.
  32. Thank-you for sharing your shopping experiences so WIC can continue to improve services to families in the community.
  34. TCHD Website color Capture
  36. This institution is an equal opportunity provider.
    37. Leave This Blank:

  39. This field is not part of the form submission.