WIC Pre-Application

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Please correct the field(s) marked in red below:

Please complete the boxes below. A Chippewa County WIC Program staff person will phone you to complete your application for WIC services within 2 business days. If you prefer to not complete this form OR would like to speak now to a WIC staff person, please phone 715-726-7903 or 800-400-3678.

Thank you for your interest in the WIC Program.

 

1

First Name

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2

Address

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Address
3

Daytime Telephone

 *
4

Household Income Before Taxes

Household Income Before Taxes
5

Are You Pregnant?

 *
Are You Pregnant?
6
How many people live in your household? Be sure to count unborn baby if you are pregnant.
 *
7

Have you had a baby in the last 6 months?

 *
Have you had a baby in the last 6 months?
8

Are you breastfeeding a baby who is less than one year of age?

 *
Are you breastfeeding a baby who is less than one year of age?
9

Please list the First Name(s) of Your Children Under Age 5

10
How did you hear about WIC? (Check all that apply)
How did you hear about WIC? (Check all that apply)
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