Application

Well WIC Worksite Certification Form
Welcome! Your agency has made it to the final step to becoming a certified Well WIC Worksite. In order to complete the final step, please fill out the form below and submit with any applicable documents.
Primary Agency Contact:*

First Name Last Name
Email Address*
example@example.com
Wellness Coordinator (if different from Primary Agency Contact)

First NameLast Name
Wellness Coordinator Email (if different from Primary Agency Contact)
example@example.com
Agency:*
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeUnited States
Phone Number*
Format: (000) 000-0000.
Write a 1-2 page summary of your WIC Worksite Wellness program. Include success stories, how the program has helped your agency overall, and some activities/objectives that you felt were most successful.Submit your Worksite Wellness summary (upload Word document(s) below).
Please attach a Word Doc of your Wellness Summary

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Congratulations!

Once we receive this form and your summary, and once we review your documents, we will send you an email confirmation and follow up with a discussion about options for presenting your certification plaque. We look forward to certifying your agency and acknowledging all your successes as a Certified Well WIC Worksite! Please email Jenniffer Duran-West at jduranwest@calwic.org with questions.
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Well WIC Worksite Certification Form