Teletask

WIC Application

Please provide the following information. If you are eligible, a WIC counselor will contact you to schedule an appointment.

*If you receive Medi-cal, Cal Fresh, or TANF you may be income eligible.

1. What would you like to do? *

Apply (new applicant)

Re-Apply (less than 2 years since last received WIC benefits)

Transfer to Stanislaus County from another county/state

Enroll newborn(s)

2. If you are a current WIC participant, please provide your family ID or WIC card #

3. Is this a foster family? *

Yes

No

4. If this is a referral, what agency are you referring from?

5. First Name *

6. Last Name *

7. Date of Birth (MM/DD/YYYY) *

8. Physical Address *

9. City *

10. Zip Code *

11. Phone Number (###) ###-##### *

12. Preferred Language *

13. Is an interpreter needed for appointments?

Yes

No

14. Are you (Check all that apply): *

Pregnant

Breastfeeding

Have child(ren) under the age of 5 years

Postpartum (had a pregnancy loss less than 6 months ago)

15. Are you currently receiving Medi-cal, TANF, or CalFresh? *

Yes

No

16. Which office would you like to go to? *