WIC Intake Form

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WIC Intake Form

We are excited to help serve you through Ottawa County WIC!

WIC is a supplemental nutrition program for pregnant and postpartum women, infants, and children up to age 5. This program is income based and food is issued through an electronic benefits (EBT) card. Monthly food packages are based on pregnancy or the age of the children.

Please complete the following intake form and a member of our staff will follow up with you to schedule an appointment.

At the time of your appointment we would ask that you please bring an ID, current pay stubs, and proof of residency. If you have any questions you can call our office at 419-734-6800, just ask for WIC!

Your Name *

Address *

Phone Number *

Best time to reach you

Morning

Afternoon

Clear selection

What is your date of birth

YYYY

Are you currently pregnant?

Yes

Clear selection

Number of people in your home, including the baby if you are currently pregnant.

Names of children under 5 in your home and their date of birth.

Are any children in your home in foster care or kinship?

Yes

Clear selection

Have you ever been on WIC before?

Yes

Clear selection

If yes, where?

Do you have Medicaid insurance?

Yes

Clear selection

If yes, what plan do you have (Buckeye, Anthem, Caresource...)

Do you currently receive any county or state benefits?

SNAP- Food Assistance

TANF

Kinship

Clear selection

What is your current monthly income for the household?

How did you hear about WIC?

Enter date completed *

YYYY

This institution is an equal opportunity provider.

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