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Scott and Carver County WIC screening tool
Leave This Blank:
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:
* indicates required fields.
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