Application for the Idaho WIC Program

WIC is an equal opportunity provider. For the full nondiscrimination statement and contact information to file a complaint, please visit the Idaho WIC website at www.wic.dhw.idaho.gov.

SECTION A – Contact Information

Please complete all sections of the application

Physical Address

Telephone

SECTION B – Applicant Information

Please answer the following questions.

List all individuals (pregnant women, breastfeeding women up to 12 months from delivery, postpartum women up to 6 months from delivery, infants and children under 5 years) who are applying for WIC services. Include due date of unborn children in the space for name.

(Ethnicity, sex and race data are for statistical purposes only. They are not used to determine eligibility. If you choose not to answer, WIC staff will select for you.)

Applicant 1

Applicant 2

Applicant 3

Applicant 4

Applicant 5


* These fields are required.