Health Services Agency

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!

All fields marked with an asterisk are required, and must be filled in.

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

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

Mailing Address (if different from above):

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

Date of Birth: / MM / DD YYYY

Sex: Female Male

Ethnicity: Asian Black Hispanic Native White

Name of Person #2

Date of Birth: / MM / DD YYYY

Sex: Female Male

Ethnicity: Asian Black Hispanic Native White

Name of Person #3

Date of Birth: / MM / DD YYYY

Sex: Female Male

Ethnicity: Asian Black Hispanic Native White

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:

Is this a referral? YES NO *

If YES, what agency are you referring from?

If you are booking an appointment on behalf of a WIC applicant please provide a phone number and email to reach you at.