Stanislaus County Health Services Agency

WIC Pre-Application Information Online

Please fill in the blanks and select the appropriate answer to assist in making your application. Click SUBMIT and someone will contact you. Thank you!

Applicant's Name (mother, father, OR caregiver):

First:
Last:

Applicant's Middle Initial:

Date of Birth / MM / DD YYYY

Marital Status: Single Married Divorced

Is this a foster family? YES NO

Preferred Language:

Are any of the applicants receiving TANF, Medi-Cal, or Food Stamps?
YES NO

Are you or any of your family on the Commodity Supplemental Food Program (CSFP)?
YES NO

How many people in your family?

What is your family's monthly income BEFORE taxes?

Are you homeless? YES NO

Street Address:
Address Line 2:
City:
State / Province / Region:
Postal / Zip Code:

Mailing Address (if different from above):

Street Address:
Address Line 2:
City:
State / Province / Region:
Postal / Zip Code:

Phone Number: - (###) - ### ####

Is this a message phone? YES NO

Additional Applicants
(Pregnant, breastfeeding, or postpartum woman, and children in the home under the age of 5 years) :

Name of Person #1

First:
Last:

Date of Birth: / MM / DD YYYY

Sex: Female Male

Ethnicity:

Name of Person #2

First:
Last:

Date of Birth: / MM / DD YYYY

Sex: Female Male

Ethnicity:

Name of Person #3

First:
Last:

Date of Birth: / MM / DD YYYY

Sex: Female Male

Ethnicity:

Background Information

Have you ever been on WIC in Stanislaus County? YES NO

If YES, when?

Have you ever been on WIC in another county? YES NO

If YES, where? When?

Other name(s) used - including maiden and previous marriage(s):

Mother's first name: