Wic Application Form PDF Details

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.

QuestionAnswer
Form NameWic Application Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesWhitehall, wic application form, WIC, Trempealeau

Form Preview Example

WIC APPLICATION FORM

How did you hear about the WIC Program?____________________________________

Your Name:____________________________________________________

Date of Birth:____/_____/_____

Address:

Street

 

 

City

 

Zip

 

 

County

 

Daytime Phone Number: (

)___________________________

 

 

 

 

 

 

 

 

Number of people living in your household (counting you):_______

 

 

Gross household income: $____________per:

week

2 weeks

month

year

(before taxes)

 

 

 

 

(check one)

 

 

Are you pregnant?

Yes

No

 

 

 

 

 

 

When is your expected due date? ____/____/_____

 

 

 

 

 

Have you had a baby in the last 6 months?

Yes

No

 

 

 

 

Are you breastfeeding a baby who is under one year of age?

Yes

No

 

Please list name, sex, and date of birth for each of your children under age 5:

Name

 

Sex

Birth Date

__________________________________

M

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