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? *
First name *
Middle name
Last name *
Your Date of Birth *
Phone Number *
Email Address *
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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.