WIC Application

Start your WIC application today

Thank you for your interest in the WIC program. After you submit this form, someone from your local WIC clinic will call you. WIC is a nutrition program for women, infants, and children less than 5 years old. You can start online by completing this form. However, completing the form does not guarantee your enrollment in the program, as your eligibility will be determined when you attend your first WIC appointment.

1Demographic Information > 2Dependant Information > 3Review Your Entry
What language do you prefer to speak?

What language do you prefer to speak? English Spanish Other Other
Parent/Guardian Parent/Guardian First Middle Last
Your Date of Birth Your Date of Birth / MM / DD YYYY
What is your phone number? What is your phone number? - ### - ### ####

This is so we can call you to set up an appointment.
Confirm your phone number Confirm your phone number - ### - ### ####

This is so we can call you to set up an appointment.
What is your physical address? What is your physical address?
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Have you ever been on any WIC program or are currently enrolled in a WIC program?

Have you ever been on any WIC program or are currently enrolled in a WIC program? No Yes
At which WIC location were you enrolled?
WIC benefits are for pregnant and postpartum mothers and children up to the age of 5 years.

Please select the statement(s) below that are true for you.

WIC benefits are for pregnant and postpartum mothers and children up to the age of 5 years.

Please select the statement(s) below that are true for you. I have an infant less than 1 year old. I have a child between the ages of 1 and 5 years old. I am pregnant. I am a foster parent or legal guardian of a child less than 5 years old. I experienced a pregnancy loss that was less than 6 months ago. None of the above.
Are you currently breastfeeding and/or pumping for this infant?

Are you currently breastfeeding and/or pumping for this infant? Yes No