WIC Application Form

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Please correct the field(s) marked in red below:

Participation in the WIC program is voluntary.  Completion of this form is required to determine WIC eligibility and any personally identifiable information will be used for that purpose only.

Answer the following questions to the best of your ability.  All information is secure and will be kept confidential.

Personal Information

 *
Personal Information

Household income

Household income
Are you pregnant?
Are you pregnant?
If you are pregnant:
 *
If you are pregnant:
Have you had a baby in the last 6 months?
Have you had a baby in the last 6 months?
Are you breastfeeding a baby who is under one year of age?
Are you breastfeeding a baby who is under one year of age?
Name, sex, and birth date of your children under age 5.
Name, sex, and birth date of your children under age 5.
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