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, breast and chest feeding, 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:

Benefits to buy 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.

Select a local WIC clinic

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

Please select one:

I am interested in WIC.

I am with a referring organization.

Name of your organization:

Contact Information

If you're currently enrolled in WIC, please contact your WIC clinic to report changes.

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

Please provide your contact information.

First name

Phone number

Format as ###-###-####.

Preferred Contact Method

Please provide an email address.

Text

Text number

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.

Cell phone/texting carrier

Verizon, T-mobile, etc.

Phone call

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. Please note that WIC related information will be mentioned during outreach attempts (calls, voicemails, text messages, and emails). 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).

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Thank you for your interest in the Washington WIC Program.