Thank you for your interest in the WIC program. WIC is a nutrition program for women, infants, and children less than 5 years old. Please complete this form and someone from the WIC clinic will call you to complete the process and determine your eligibility.

What language do you prefer to speak? *
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First name *	Please enter your first name.
Middle name
Last name *	Please enter your last name.
Your Date of Birth *	Please enter your birth date.
Phone Number *	Please enter your phone number.
Email Address *	Please enter your email address.
Address Line 1 *	Please enter your address.
Address Line 2
City *	Please enter name of the city you live in.
State *	Oklahoma Please select the state you live in.
Zip Code *	Please enter your zip code.

Please select the statement(s) below that are true for you. *

I have an infant less than 1 year old.

I have a child between the ages of 1 and 5 years old.

I am pregnant.

I am a foster parent or legal guardian of a child less than 5 years old.

I experienced a pregnancy loss that was less than 6 months ago.

None of the above.

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