Women, Infants, and Children (WIC) > Health Professionals > WIC Forms and Materials > Request for WIC Materials Form

Request for WIC Referral Forms and Education Materials

To send a request for printed WIC referral forms and education materials, complete the form below. Please refer to available WIC items listed on our WIC Referral Forms and Education Materials page. We can only fulfill material requests for organizations within San Bernardino County.

A WIC representative will review your submitted request and contact you during normal business hours.

WIC Material Request Form

First Name

Last Name

Email

Phone Number

Organization Name

Mailing Address

City

Zip Code

Interoffice mail code (if applicable)

For San Bernardino County offices

Please select your requested WIC item from the dropdown menu

Select language(s) needed

EnglishSpanishOther

Other language requested

If you selected "Other" language, please fill out language required other than English or Spanish.

Quantity requested in English

Quantity requested in Spanish

Quantity requested in other language

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