Application for the Wood County WIC Program

Participation in the WIC program is voluntary. Completion of this form is required to determine WIC eligibility and any personally identifiable information collected will be used for that purpose only.
Answer the following questions to the best of your knowledge. All information will be kept confidential.
Your Name
Address
City
ZIP Code
County
Daytime Telephone
Number of people in
your family (counting you)
Household Income per
Are you pregnant?
Due Date Your Birth Date
Have you had a baby in the last 6 months?
Your Birth Date
Are you breastfeeding a baby
who is under one year of age?
Name, sex, and birth date for each of your children under age 5
Name Sex Birth Date
Name Sex Birth Date
Name Sex Birth Date
Name Sex Birth Date
Name Sex Birth Date
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