What is your date of birth? *
Street Address *
Is it OK if we text you about WIC?
What is a good time to call you?
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.
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.