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Women Infants & Children (WIC) Application

  1. Women Infants and Children (WIC) Application
  2. This is my*
  3. Text Appointment Reminder Okay?
  4. This is my
  5. You, the Applicant are the:*
  6. Gender*
  7. Primary Language*
  8. Do you need an interpreter?
  9. Have you been on WIC before?*
  10. Eligibility Requirements
  11. Are you or any member of your family on MA or MN Care?*
  12. Are you or any of your family members on any of the following programs? *
  13. 1st Person's Income
  14. Overtime?*
  15. Other Sources: Do you have other income from MFIP Workers' Comp, Social Security, Child Support, SSI, or other sources?*
  16. Is there a second wage earner in your household? *
  17. 2nd Person's Income
  18. Overtime?
  19. Other Sources: Do you have other income from MFIP Workers' Comp, Social Security, Child Support, SSI, or other sources?
  20. Women
  21. Are you pregnant?*
  22. Are you breastfeeding?*
  23. Are you using formula?*
  24. Are there children under 5 in your household?*
  25. Gender
  26. Gender
  27. Gender
  28. Gender
  29. Gender
  30. 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)?
  31. Leave This Blank:

  32. This field is not part of the form submission.