CONTACT US

[208] 375-5211

Serving Ada, Boise, Elmore, and Valley Counties
MAKE A PAYMENT
PATIENT PORTAL

SECTION A – Contact Information

Please complete all sections of the application

Maiden Name (if any)

Date of Birth

Street Address *

City

Home Phone *

Work/Message Phone

SECTION B – Applicant Information

Please answer the following questions.

How many people are living in your household (include unborn child/ren)? *

Is anyone in your household receiving SNAP, TANF, Medicaid or CHIP? *

Is anyone in your household a migrant worker? *

What is the highest grade you have completed in school? *

Which WIC office would you like to receive services in? *

Where did you hear about WIC? *

List all individuals (pregnant women, breastfeeding women up to 12 months from delivery, postpartum women up to 6 months from delivery, infants and children under 5 years) who are applying for WIC services. Include due date of unborn children in the space for name.

(Ethnicity, sex and race data are for statistical purposes only. They are not used to determine eligibility. If you choose not to answer, WIC staff will select for you.)

* These fields are required.

CONTACT US

[208] 375-5211

Serving Ada, Boise, Elmore, and Valley Counties
MAKE A PAYMENT
PATIENT PORTAL

Application for the Idaho WIC Program

SECTION A – Contact Information

Physical Address

Telephone

SECTION B – Applicant Information

List all individuals (pregnant women, breastfeeding women up to 12 months from delivery, postpartum women up to 6 months from delivery, infants and children under 5 years) who are applying for WIC services. Include due date of unborn children in the space for name.

Applicant 1

Applicant 2

Applicant 3

Applicant 4

Applicant 5

CONTACT US

[208] 375-5211

Serving Ada, Boise, Elmore, and Valley Counties MAKE A PAYMENT PATIENT PORTAL

Application for the Idaho WIC Program

SECTION A – Contact Information

Physical Address

Telephone

SECTION B – Applicant Information

List all individuals (pregnant women, breastfeeding women up to 12 months from delivery, postpartum women up to 6 months from delivery, infants and children under 5 years) who are applying for WIC services. Include due date of unborn children in the space for name.

Applicant 1

Applicant 2

Applicant 3

Applicant 4

Applicant 5

Serving Ada, Boise, Elmore, and Valley Counties
MAKE A PAYMENT
PATIENT PORTAL