WIC New Patient Enrollment Form

Community Health Alliance WIC Application Form

Please fill in the form below
Name*

First NameMiddle NameLast Name
Contact Number:*

Area CodePhone Number
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*
Date of Birth*

MonthDayYear
What is the best time to contact you?
Have you ever been on WIC?*

YesNo
Are you pregnant?*

YesNo
Have you been pregnant in the last 6 months?*

YesNo
Do you or anyone in your household receive any of the following? (Select all that apply)

MedicaidTANFSNAP/Food stamps
If yes, to any of the above. Please attach benefit letter.

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Where did you hear about WIC?*

TVNewsSocial MediaFriend/Famiy
Household Size
Your household is everyone who lives in your home (including children) and shares income and household expenses (bills, food, etc.). Your household may include people who are related to you and people who are not.

Note: If a woman in your household is pregnant and applying for WIC benefits you may then increase your household size by the number of expected births. For example, a pregnant woman, with one unborn child, would increase her household size by '1'.
Number of people in household*
Childrens's name (under 5 years of age only)
Child #1

First NameLast Name
Date of Birth

MonthDayYear

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Applicant's relationship to child *
If "other", please specify
Income

Please fill out based on the income your household has received in the last 30 days.
Income Type*
Income $ amount*
Frequency of pay *

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Proof of Nevada residency (Attach here)

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I give authorization for electronic transmission of the information above to Community Health Alliance WIC. I understand this information will be used to screen my WIC eligibility. I also understand that by submitting this information, I am not guaranteed enrollment in the program. *
Signature*

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Community Health Alliance WIC Application Form