Wic Program Application - Meigs County Health Department
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1
2Ohio Department of Health
WIC Program Application
A.
Parent, guardian or applicant’s name
Telephone
B Home B Work
B Cell
B Leave message
Street address
City
State
County
ZIP
Mailing address (if not the same as street address)
City
State
ZIP
B. In the section below please list everyone who is living in your home.
1. Full name—first, middle, last
Relationship to you
Date of birth
B
Male
/
/
B
Female
Hispanic/Latino
If pregnant: number
Due date
B
B
B
American Indian /Alaskan Native
Asian
White
/
/
of unborn babies
B
B
B
B
Yes
No
Native Hawaiian/Other Pacific Islander
Black/African American
2. Full name—first, middle, last
Relationship to you
Date of birth
B
Male
/
/
B
Female
Hispanic/Latino
If pregnant: number
Due date
B
B
B
American Indian /Alaskan Native
Asian
White
/
/
of unborn babies
B
B
B
B
Yes
No
Native Hawaiian/Other Pacific Islander
Black/African American
3. Full name—first, middle, last
Relationship to you
Date of birth
B
Male
/
/
B
Female
Hispanic/Latino
If pregnant: number
Due date
B
B
B
American Indian /Alaskan Native
Asian
White
/
/
of unborn babies
B
B
B
B
Yes
No
Native Hawaiian/Other Pacific Islander
Black/African American
4. Full name—first, middle, last
Relationship to you
Date of birth
B
Male
/
/
B
Female
Hispanic/Latino
If pregnant: number
Due date
B
B
B
American Indian /Alaskan Native
Asian
White
/
/
of unborn babies
B
B
B
B
Yes
No
Native Hawaiian/Other Pacific Islander
Black/African American
5. Full name—first, middle, last
Relationship to you
Date of birth
B
Male
/
/
B
Female
Hispanic/Latino
If pregnant: number
Due date
B
B
B
American Indian /Alaskan Native
Asian
White
/
/
of unborn babies
B
B
B
B
Yes
No
Native Hawaiian/Other Pacific Islander
Black/African American
6. Full name—first, middle, last
Relationship to you
Date of birth
B
Male
/
/
B
Female
Hispanic/Latino
If pregnant: number
Due date
B
B
B
American Indian /Alaskan Native
Asian
White
of unborn babies
/
/
B
B
B
B
Yes
No
Native Hawaiian/Other Pacific Islander
Black/African American
C.
If anyone in your home is pregnant, is she under a doctor’s care?
If yes, what is the doctor’s name?
B
B
Yes
No
D.
Has anyone in your home had a pregnancy that ended within the last six months?
If so, who?
B
B
Yes
No
E.
Is anyone in your home breastfeeding a baby less than 12 months old?
If so, who?
B
B
Yes
No
F. Please check Yes or No if anyone in your home is receiving any of the following:
B
B
B
B
B
B
Ohio Works First Cash
Yes
No
Medicaid
Yes
No
Food Assistance
Yes
No
If so, who?
If so, who?
If so, who?
For each person in your home who has any income such as wages, self-employment, unemployment, SSI, Social Security,
VA pension, workers compensation, alimony, child support, lump-sum payments, please complete the lines below.
Name
Name of income source
Gross amount
How often received
$
$
$
Important!
You must sign the back of this application form.
HEA 4460 (Rev. 1/10)
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