WIC Eligibility Application Form - English

WIC Form

Required fields are marked with an asterisk (*).

1. Date
2. Name *
3. Phone Number *
4. When is the best time to contact you? * Please Select Anytime Morning Afternoon
5. Can we leave a message OR text you? * Please Select Yes, Call Yes, Text Yes, Call/Text No
6. Address
7. City *
8. State * Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
9. Zip
10. County *
11. Email *
12. Do you or family members fall into the following categories? (check all that apply)

    Pregnant
    Breastfeeding
    Infant - under age 1 yr
    Child - under age 5 yr
    
13. Have you been on WIC in Iowa before? * Please Select Yes No
14. Are you on WIC in Iowa now? * Please Select Yes No
15. Do you receive Medicaid? * Please Select Yes No
16. Do you receive SNAP benefits? * Please Select Yes No
17. Is there anything else you want us to know?
18. How did you find out about the WIC Program? * Please Select Friend/Family Doctor Hospital Human Services Other
19. Other
20. reCAPTCHA