Search
Search
En Español
In English
En Español
In English
Close Trigger
Search
Search
Application Form - American Red Cross
Application Form - American Red Cross
Parent / Guardian Name
*
Parent / Guardian Name
First
First
Last
Last
Parent / Guardian D.O.B
Does anyone in your family have Medi-Cal?
Yes
No
Medi-Cal # for parent/guardian
Children Information
Child Name
Child Name
First
First
Last
Last
Child D.O.B (only children under 5 are eligible)
Medi-Cal # for child
plus1
Add
minus1
Remove
Preferred language
Phone
*
Email
*
Physical Address
Physical Address
Physical Address
Physical Address
City
City
State/Province
State/Province
Zip/Postal
Zip/Postal
Physical Address
Monthly household income
Is there any active military member in your family?
Yes
No
Is there a foster child in your family?
Yes
No
Additional Comments
How did you hear about WIC?
*
From a friend/family member
From my doctor/healthcare provider
At a community event
Naval Hospital Camp Pendleton (NHCP)
Naval Medical Center San Diego (NMCSD)
Head Start/Early Head Start
CalFresh
Social Media
Other
Other
Submit
If you are human, leave this field blank.
<
<
Home
Parent or Guardian
Healthcare Provider
Community Organizations
Welcome to WIC
Home
Parent or Guardian
Healthcare Provider
Community Organizations
Welcome to WIC
Refer Someone
Refer Someone New
Agency/ organization name
Referred by name
Agency email address
Did agency deliver WIC orientation?
Yes
No
Parent's name
Parent's name
First
First
Last
Last
Parent's date of birth
Is the parent pregnant?
Yes
No
Enrolled in MediCal?
Yes
No
Parent's Medi-Cal number (if applicable)
Address
Address
Address
Address
City
City
State/Province
Alabama
Alaska
Arkansas
Arizona
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State/Province
Zip/Postal
Zip/Postal
Address
Children under age 5
Child's name
Child's name
First
First
Last
Last
Child's date of birth
Child's Medi-Cal number (if applicable)
plus1
Add
minus1
Remove
Monthly income (if known)
$0-$2000
$2000-$4000
$4000 or more
Does the parent speak English?
Yes
No
Preferred language:
Preferred contact method
Call
Text
Email
Phone number
If this is not the parent's direct number, please write whose it is in this field next to the phone number
Email address
If this is not the parent's direct email, please write whose it is in this field next to the email address
Other notes/ comments
Permission for WIC to contact them?
Yes
No
This agreement to release personal information will begin on July 1, 2023 and will end on June 30, 2024.
Yes I, the parent/guardian, consent
Submit
If you are human, leave this field blank.
