The Wic application form is an important document for Witches. It is used to record the magical and religious information of a witch, as well as their personal history. The form can be used to track any magical progress made by the witch, as well as any rituals or ceremonies they have participated in. Completing the form can be a very valuable tool for witches, and can help them grow in their craft.
| Question | Answer |
|---|---|
| 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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City |
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County |
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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: |
week |
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 |
__________________________________ |
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