WIC Application

Name *

Phone *

Text Message * Yes
No

Have you been on WIC in Wisconsin or another state? Yes
No

Do you or your children receive Forward Health/BadgerCare? Yes
No

Total Household income before taxes (including child support, SSI, disability)

Total household income is per: Week
Two Weeks
Month
Year

Do you have any children under the age of 5? Yes
No

Are you pregnant? Yes
No

If Yes, When is your expected due date?

Have you had a baby in the last 6 months? Yes
No

Are you breast feeding a baby who is under one year of age? Yes
No