Wood County, Wisconsin

Official Website

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.

Are you a nurse or other health professional filling this out as a patient referral to WIC? NoYes

Have you previously received WIC benefits? NoYes

Is this a new or updated application? NewUpdate

Preferred Appointment Location Wisconsin RapidsMarshfield

Your First Name

Your Last Name

Preferred Pronouns

Previous Last Name(s)

Your Birth Date

Address

City

ZIP Code

County

Daytime Telephone

Number of people in your family (counting you)

Household Income

per

Are you pregnant? NoYes

Due Date

Have you had a baby in the last 6 months? NoYes

Are you breastfeeding a baby who is under one year of age? NoYes

Name, sex, and birth date for each of your children under age 5

Child 1

Name

Sex MF

Birth Date

Child 2

Name

Sex MF

Birth Date

Child 3

Name

Sex MF

Birth Date

Child 4

Name

Sex MF

Birth Date

Child 5

Name

Sex MF

Birth Date

Would you like a language interpreter for your WIC appointment? NoYes

If requesting an interpreter, what language?

This institution is an equal opportunity provider.
WIC: Non Discrimination Statement: English, En Español, and Hmong

Submit Application