WIC Eligibility Assessment Form

Please fill out the form below. Fields with a red (*) asterisk are required fields.

Have you ever been on the WIC program before?
If you answered YES to the question above, please list when you were last seen and where?
Do you live in the greater Sacramento area, Galt or Walnut Grove?
Which office would you like to go to?
First Name
Last Name
Is this a foster family?
What is your preferred language?
Do you currently receive Medi-Cal, Cal-Fresh, or TANF?
How many people live in your current household (if you are pregnant include unborn infant)?
What is the estimated total monthly income for the entire household before taxes?

Physical Address
Zip Code
Alternate Phone Number
Enter the code shown above in the box below.