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WIC Pre-Qualification Form

Thank you for your interest in applying for WIC. Please provide the following information so our staff can contact you to review your eligibility and to schedule a certification appointment. We will make every attempt to contact you within the work week. If you don’t hear from us by then or have more immediate needs, please contact us by phone at (608) 267-1111.

Read our Privacy Practices Notice to learn how medical information about you may be used and disclosed and how you can get access to this information. The privacy of your medical information is important to us.

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Contact Information

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Please note that our office hours are M-F, 8-4:30 pm. This is when we are available to call you.

Household Income Information

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Include any unborn babies
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Include child support, grants, and scholarships
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