The process of applying for the Women, Infants, and Children (WIC) Program requires applicants to fill out a comprehensive form designed to collect essential personal and financial information. Applicants begin by indicating how they learned about the WIC Program, a significant piece of information that helps in tracking the program's outreach efforts. The form requests detailed personal information such as the applicant’s name, date of birth, address, and contact number, ensuring that the program can maintain effective communication with applicants. Additionally, it requires applicants to disclose their household size and gross income, which are critical for determining eligibility based on financial needs. The form also inquires about specific conditions like pregnancy, recent childbirth, and breastfeeding status, to tailor the program's nutritional support to the applicant's specific stage of motherhood. It further asks for the name, sex, and date of birth for each child under the age of five living in the household, which helps the program understand the need for nutritional support within the family. The flexibility of submitting the form either through mail or electronically via email addresses the diverse needs of applicants, making it convenient to apply from anywhere. This meticulously designed application form embodies the program’s commitment to supporting the nutritional needs of women, infants, and children by gathering vital information to ensure those most in need receive assistance.
Question | Answer |
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Form Name | Wic Application Form |
Form Length | 1 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 15 sec |
Other names | Whitehall, wic application form, WIC, Trempealeau |
WIC APPLICATION FORM
How did you hear about the WIC Program?____________________________________
Your Name:____________________________________________________
Date of Birth:____/_____/_____
Address:
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Daytime Phone Number: ( |
)___________________________ |
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Number of people living in your household (counting you):_______ |
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Gross household income: $____________per: |
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2 weeks |
month |
year |
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(before taxes) |
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(check one) |
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Are you pregnant? |
Yes |
No |
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When is your expected due date? ____/____/_____ |
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Have you had a baby in the last 6 months? |
Yes |
No |
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Are you breastfeeding a baby who is under one year of age? |
Yes |
No |
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Please list name, sex, and date of birth for each of your children under age 5:
Name |
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Sex |
Birth Date |
__________________________________ |
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F |
____/_____/____ |
__________________________________ |
M |
F |
____/_____/____ |
__________________________________ |
M |
F |
____/_____/____ |
__________________________________ |
M |
F |
____/_____/____ |
__________________________________ |
M |
F |
____/_____/____ |
This form can be printed, filled out, and mailed to:
Trempealeau County WIC Program
36245 Main Street
PO Box 67
Whitehall, WI 54773
OR the form can be filled in electronically and emailed to:
ashort@tremplocounty.com