WIC - Request Appointment
First Name * (Parent/Caregiver or Guardian)
Last Name * (Parent/Caregiver or Guardian)
Are you pregnant?
If yes, due date

Contact Information:

Primary Phone Number *
Alternate Phone Number
E-Mail Address
Address
City/Town
Zip

Children's Information:

Please list the names of children who are under 5 years old

#1 Child's Name
Date of Birth Please enter month and year of birth, mm/yyyy
Gender
#2 Child's Name
Date of Birth Please enter month and year of birth, mm/yyyy
Gender
#3 Child's Name
Date of Birth Please enter month and year of birth, mm/yyyy
Gender
Primary Language of the Family
Do you have Mass Health?
Food Stamps?
Captcha *
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Contact WIC

Haverhill: (Main Northern Essex WIC Office)
(978) 374-2191
Community Action, Inc.
145 Essex Street
Haverhill, MA 01832
Directions

Hours: Mon, Wed, Thu
& Fri: 9am - 5pm | Tues:
10:30am - 6:30pm | One
Saturday per month:
9am - 2pm

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