WOW Request Form

Bring Wellness on Wheels to Your Community!

To schedule a Wellness on Wheels unit for your community, please fill out the form below and we will get back to you with available dates.

Business Name: *

South Dakota Town: *

Contact Person's First and Last Name: *

Contact Person's phone number: *

Contact person's email address: *

Which programs/services would you like provided on site? *

WIC Supplemental Nutrition

Pregnancy Care

Safe Sleep

Maternal Depression Screening

Developmental Screening

Immunizations

Oral Health

Sexually Transmitted Infection Testing

Please select as many as you'd like.

Do you have a preference on day of the week/time/time of the month? If so, please list below.

How often would you like Wellness on Wheels to visit your site?

Security check *