Parent/Adult's First Name *	Parent/Adult's Last Name *

What is your date of birth? *

Street Address *

City *

State * Zip *

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Phone *	Email

Is it OK if we text you about WIC?

What is a good time to call you?

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

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

How did you hear about WIC?

* denotes a required field.