WIC Interest Form

Thank you for your interest in the Oregon WIC program. WIC serves pregnant, postpartum or breastfeeding women or children under 5 years old. Dads, grandparents, foster parents or other guardians may apply for WIC for their children. By filling out the form below, your information will be sent to the Crook County Health Department. If you qualify for the WIC program, a staff member will reach out to you.

Type Of Referral: *
Self/Parent/Guardian First Name
Self/Parent/Guardian Last Name
Date of Birth:
Self/Parent/Guardian Birthday
Are you pregnant?: *
Pregnancy due date:
Are you parenting a child/children under the age of 5 years old?: *
Do you need breastfeeding support?: *
Is anyone in your household enrolled in OHP, SNAP, or TANF? *
Self/Parent/Guardian pronouns *
Please fill in your name. By entering your name you are approving the submitting of this form to the Crook County Health Department.
Date:
I understand that an employee from Crook County Health Department WIC Program will contact me to find out if I qualify for WIC. *
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