WIC Interest Form

Thank you for your interest in the Washington Women, Infants and Children (WIC) Nutrition Program!

WIC is for people who are pregnant, recently delivered a baby, breastfeeding, and infants and children under 5 years old. Dads, grandparents, foster parents or other guardians may apply for WIC for their children.

If you or your children have state health insurance (Medicaid) or receive SNAP benefits, you may qualify. Many working families and military families are eligible for WIC.

WIC provides:

  • Up to $60 per person in free healthy food each month
  • Health screenings
  • Nutrition education
  • Breastfeeding support
  • Referrals to other health and social services

Interested individuals or referring organizations can submit this form and a local WIC clinic will contact you.

Use the drop-down list below or WIC Clinic Locator Map to choose your WIC clinic.

Contact Information

Please provide the contact information of the person you are referring.

Please provide your contact information.

Preferred Contact Method

Please provide a texting number if different from your phone number above.
Some WIC clinics are not able to text at this time and will call instead.
Primary Language

By submitting this form, you consent to receive communication from WIC and understand we will share your information with local WIC agencies for outreach and enrollment purposes. Do not enter any confidential information such as information about your health. Information collected via this form may be subject to release in accordance with RCW 42.56 (Public Records Act).

CAPTCHA
1 + 0 =
Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.

Thank you for your interest in the Washington WIC Program.