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Women Infants & Children (WIC) Application

2. Women Infants and Children (WIC) Application

4. First Name*

5. Middle Initial*

6. Last Name*

8. Birthdate*
   Birthdate

10. Address*

12. City*

13. State*

14. Zip Code*

16. Phone*

17. This is my*

    1. Home
    2. Work
    3. Mobile

18. Text Appointment Reminder Okay?

    1. Yes
    2. No

20. Alternative Phone

21. This is my

    1. Home
    2. Work
    3. Mobile

23. Email*

27. You, the Applicant are the:*

    1. Mother
    2. Father
    3. Foster Parent / Guardian / Other

28. Gender*

    1. Male
    2. Female

30. Primary Language*

    1. English
    2. Spanish
    3. Somali
    4. Other

31. Do you need an interpreter?

    1. Yes
    2. No

33. Have you been on WIC before?*

    1. Yes
    2. No

35. Where were you previously on WIC?

39. Eligibility Requirements

41. Current number in household (include unborn baby) *

42. Are you or any member of your family on MA or MN Care?*

    1. Yes
    2. No

44. Are you or any of your family members on any of the following programs? *

    1. SNAP
    2. Free / Reduced School Lunch
    3. Fuel Assistance
    4. Head Start
    5. MFIP
    6. TEFRA
    7. SSI
    8. None of the above

48. 1st Person's Income

50. Hourly Wage*

51. Hours per Week*

52. Overtime?*

    1. Yes
    2. No

53. Average overtime hours per week:

55. Other Sources: Do you have other income from MFIP Workers' Comp, Social Security, Child Support, SSI, or other sources?*

    1. Yes
    2. No

57. Source

58. Amount

59. Source

60. Amount

62. Other Income

64. Is there a second wage earner in your household? *

    1. Yes
    2. No

68. 2nd Person's Income

70. Hourly Wage

71. Hours per Week

72. Overtime?

    1. Yes
    2. No

73. Average overtime hours per week:

75. Other Sources: Do you have other income from MFIP Workers' Comp, Social Security, Child Support, SSI, or other sources?*

    1. Yes
    2. No

77. Source

78. Amount

79. Source

80. Amount

82. Other Income

86. Women

88. First Name*

89. Middle Initial*

90. Last Name*

92. Birthdate*
    Birthdate

93. Are you pregnant?*

    1. Yes
    2. No

94. My due date is:
    My due date is:

96. Are you breastfeeding?*

    1. Yes
    2. No

97. Are you using formula?*

    1. Yes
    2. No

98. What brand of formula are you using?

102. Are there children under 5 in your household?*

     1. Yes
     2. No

103. Number of children under 5 in your household:

105. 1st Dependent's Name

106. Middle Initial

107. Last Name

109. Birthdate
     Birthdate

110. Gender

     1. Male
     2. Female

112. 2nd Dependent's Name

113. Middle Initial

114. Last Name

116. Birthdate
     Birthdate

117. Gender

     1. Male
     2. Female

119. 3rd Dependent's First Name

120. Middle

121. Last Name

123. Birthdate
     Birthdate

124. Gender

     1. Male
     2. Female

126. 4th Dependent's First Name

127. Middle

128. Last Name

130. Birthdate
     Birthdate

131. Gender

     1. Male
     2. Female

133. 5th Dependent's First Name

134. Middle

135. Last Name

137. Birthdate
     Birthdate

138. Gender

     1. Male
     2. Female

140. Additional Information you would like us to consider .

142. Link to WIC Non-Discrimination Statement
     https://www.health.state.mn.us/people/wic/nondiscrim.html

144. Public Health Nurse Outreach

     Our Public Health Nursing staff can provide information on healthy pregnancies, giving birth, breastfeeding, parenting, and other helpful resources. Do you give us permission to share your contact information with the nurses at First Steps MN (a team of personal nurses from Benton, Sherburne, Stearns and Wright Counties in Central Minnesota)?

     1. Yes
     2. No
Leave This Blank:


146. 1. Receive an email copy of this form.
147. Email address

     This field is not part of the form submission.

148. Submit Submit and Print

* indicates a required field