Your First Name *	Your Last Name *

What is your date of birth? *

Street Address *

City *

State * Zip *

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Phone *	Email

Text me about my WIC application.

By checking this box, you agree to receive text messages from WIC about your WIC application and benefits. Message frequency varies. Message and data rates apply. Text STOP to cancel.

When is a good time to call you? Mornings (between 9:00 AM - 12:00 PM) Afternoons (between 12:00 PM – 5:00 PM) Anytime

Preferred Language *	Secondary Language
English Spanish Arabic Armenian Cambodian Chinese - Cantonese Chinese - Mandarin Dari Farsi French German Hearing Impaired Hindi Japanese Korean Lahu Laotian Mien Nepalese Pashto Polish Porguguese Punjabi Russian SEA Tagalog Thai Tigrinian Urdu Vietnamese Other	English Spanish Arabic Armenian Cambodian Chinese - Cantonese Chinese - Mandarin Dari Farsi French German Hearing Impaired Hindi Japanese Korean Lahu Laotian Mien Nepalese Pashto Polish Porguguese Punjabi Russian SEA Tagalog Thai Tigrinian Urdu Vietnamese Other

Please list the first and last names and dates of birth for all WIC applicants in your family. Include all individuals who are pregnant or have been pregnant in the last 6 months, and include all children in your care under five years old.

Name *	Date Of Birth *

If you are applying for WIC benefits for more than 6 people, additional applicants may be added by phone during your WIC enrollment appointment.

Are you or any of the applicants listed above pregnant? * Yes No

Do any of the applicants above have Medi-Cal? (Not required to participate in WIC). Yes No

Have you ever been on WIC? If yes, how long ago?

How did you hear about WIC?

  I have received WIC’s income guidelines using my gross income (before taxes).

* denotes a required field.