WIC Application Form at a glance
What it is: The WIC Application Form of the Trempealeau County WIC Program can be printed, filled out, and mailed or filled in electronically and emailed.
Where and when to file: The form can be filled in electronically and emailed to: ashort@tremplocounty.com.
A filled-in WIC Application Form example: a pregnant mother applies for WIC
How to fill out WIC Application Form, box by box
How you hear about the WIC Program, your name and date of birth
How did you hear about the WIC Program?
Write Your Name and Date of Birth: month, day, year.
Your address and daytime phone number
Write your Address: Street, City, Zip, County.
Write your Daytime Phone Number.
Number of people in your household and gross household income
Write the Number of people living in your household (counting you).
Write your Gross household income (before taxes) per week, 2 weeks, month or year (check one).
Pregnancy, a baby in the last 6 months and breastfeeding
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
Children under age 5
Please list name, sex, and date of birth for each of your children under age 5 (Birth Date: month, day, year).
Common questions about WIC Application Form
Where do I file it?
This form can be printed, filled out, and mailed to: Trempealeau County WIC Program 36245 Main Street PO Box 67 Whitehall, WI 54773
Sources
[1] WIC Application Form, Trempealeau County WIC Program (served file, edition not printed) (the Official source link on this page).