WIC Application Parent or Guardian Name * First Name Last Name Parent or Guardian Birth Date MM DD YYYY Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Can we text you an appointment reminder? Do you need an interpreter or any accommodations for a disability? Phone * (###) ### #### Number of people in your family (include baby if pregnant) Years of education? Total household income (before taxes) How did you hear about WIC? Do you or your family receive medical assistance? Do you or your family receive food share? Are you pregnant? Names, Sex, and Birthdate of your children under the age of 5 Have you or your child(ren) been on WIC before? If yes, when and where? Any comments or requests? Thank you!