Women, Infants and Children (WIC) Application

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Please correct the field(s) marked in red below:

Have you ever applied or been on WIC in the past?
Have you ever applied or been on WIC in the past?
FULL NAME
FULL NAME
FULL ADDRESS
FULL ADDRESS
PHONE NUMBER
 *
Number of people in your family (Counting You)
Number of people in your family (Counting You)
How many of your children are under the age of 5?
How many of your children are under the age of 5?
Are you pregnant?
Are you pregnant?
If so, what is your due date?
Have you had a baby in the last 6 months?
Have you had a baby in the last 6 months?
Are you breastfeeding a baby who is under one year of age?
Are you breastfeeding a baby who is under one year of age?
State the BI-WEEKLY household income before taxes?
YOU MAY AUTOMATICALLY QUALIFY - If you participate in programs such as BadgerCare, FoodShare or W-2 (Wisconsin Works) regardless of your family's income you may qualify for WIC.
Which other programs do you participate in?
Which other programs do you participate in?
  1. To receive a copy of your submission, please fill out your email address below and submit.