First Name*

Last Name*

Address*

City*

State*

Zip

Phone*

Email Address

Total number of people in the household (including children over age 5, parents/sibling, significant others/spouses)

Please list the names and birthdates of the pregnant, breastfeeding, or newly postpartum mother and all children under age 5:

Name*

Date of birth*

Name

Date of birth

Name

Date of birth

Name

Date of birth

Name

Date of birth

Services receiving: please check all that apply:

Medical Assistance Enrolled in Headstart or on waitlist Receiving Energy Assistance MNCare

MFIP/Financial Assistance Receiving Supplemental Security Income Free or Reduced School Lunch SNAP/Food Stamps

List all earnings (before tax income) in the household, including social security benefits and child support payments.

Income:

Hours worked per week

Payment frequency:

Annual Monthly

Bi-weekly Hourly

Social security income per month

Child support payments per month

Additional income per month

Have you been on WIC before?*

Yes

No

If you have been on WIC in the past, under what last name?

Are you interested in learning about these other Family Health programs within Scott County Public Heath?

Family Home Visiting Follow Along Program

Parents as Teachers Child and Teen Checkups

Additional information or comments you would like us to know: