Women, Infants, and Children (WIC)

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Women, Infants & Children (WIC)
WIC Appointment Form

Thank you for completing the WIC Appointment Form A member of our staff will review your information and check available times then contact you by email or phone to schedule your appointment.

WIC Referral

Application Progress

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Which of these applies to you?

I live in Davis County

I plan to move to Davis County

Neither of these applies to me

Not Sure

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Which of these best applies to you? I am pregnant I am breastfeeding an infant less than 12 months old I just had a baby or was pregnant within the last six months I am the parent of a child under age 5 I am the caretaker (i.e. grandparent) or foster parent of a child under age 5 I am currently receiving WIC benefits from another state None of these apply to me

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Household Size

If you are pregnant, count each baby you are expecting as one person.

Do not count foster children in your household size. Foster children under age 5 qualify for WIC on their own.

How many people are in your household?

Income Guidelines

Your household’s income before taxes (gross income) must be at or below the amounts listed below in order to quality for WIC benefits.

Learn more about WIC

Do you meet the income guidelines for your household size? Yes No Maybe

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WIC Appointment Request Form

Mother or Parent's First Name:

Mother or Parent's Last Name:

Mother or Parent's Phone Number:

Mother or Parent's Email:

Mother or Parent's Date of Birth:

Mother or Parent's Address:

Has anyone in your family received WIC benefits in Utah in the last five years?

Yes

Yes (Out of State)

Select days and times you are available for an appointment?

Monday

Morning

Afternoon

Anytime

Tuesday

Morning

Afternoon

Anytime

Wednesday

Morning

Afternoon

Anytime

Thursday

Morning

Afternoon

Anytime

Friday

Morning

Afternoon

Anytime

How would you like to be contacted?

Phone Call

Text Message

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Mother's Demographic Information

Mother's race:

White

Black or African American

Asian

Native Hawaiian or Pacific Islander

American Indian or Alaskan Native

Mother's Ethnicity:

Hispanic/Latino

Non-Hispanic/Non-Latino

Preferred Language:

Mother's Highest Education Level

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Application Progress

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Child's Demographic Information

Child's First Name:

Child's Last Name:

Child's Date of Birth or Estimated Due Date:

Child's Gender:

Male

Female

Child's race:

White

Black or African American

Asian

Native Hawaiian or Pacific Islander

American Indian or Alaskan Native

Child's Ethnicity:

Hispanic/Latino

Non-Hispanic/Non-Latino

Would you like to add a second child?

Yes

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Child 2 Demographic Information

Child's First Name:

Child's Last Name:

Child's Date of Birth or Estimated Due Date:

Child's Gender:

Male

Female

Child's race:

White

Black or African American

Asian

Native Hawaiian or Pacific Islander

American Indian or Alaskan Native

Child's Ethnicity:

Hispanic/Latino

Non-Hispanic/Non-Latino

Would you like to add a third child?

Yes

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Child 3 Demographic Information

Child's First Name:

Child's Last Name:

Child's Date of Birth or Estimated Due Date:

Child's Gender:

Male

Female

Child's race:

White

Black or African American

Asian

Native Hawaiian or Pacific Islander

American Indian or Alaskan Native

Child's Ethnicity:

Hispanic/Latino

Non-Hispanic/Non-Latino

Would you like to add a fourth child?

Yes

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Child 4 Demographic Information

Child's First Name:

Child's Last Name:

Child's Date of Birth or Estimated Due Date:

Child's Gender:

Male

Female

Child's race:

White

Black or African American

Asian

Native Hawaiian or Pacific Islander

American Indian or Alaskan Native

Would you like to add a fifth child?

Yes

Child's Ethnicity:

Hispanic/Latino

Non-Hispanic/Non-Latino

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Child 5 Demographic Information

Child's First Name:

Child's Last Name:

Child's Date of Birth or Estimated Due Date:

Child's Gender:

Male

Female

Child's race:

White

Black or African American

Asian

Native Hawaiian or Pacific Islander

American Indian or Alaskan Native

Child's Ethnicity:

Hispanic/Latino

Non-Hispanic/Non-Latino

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Confirm Eligibility

To confirm whether you qualify, call 801-525-5010.

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Transfer Of Records

If you had benefits out of State in the last 12 months, please contact the previous clinic and ask them to FAX your "VOC," to 801-525-5011 or email to ClearfieldWicKids@co.davis.ut.us.

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You may not Qualify

Based on your answers, you may not qualify for WIC because:

You are not pregnant
You are not breastfeeding an infant less than 12 months old
You were not pregnant or miscarried in the last six months
You do not care for a child under age five
You have not transferred your WIC benefits from another state to Utah

To confirm whether you qualify, call Davis County WIC at 801-525-5010.

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May not be eligible

Based on your answers, you may not be eligible because you need to live in Davis County to receive WIC benefits in Davis County.

If you live somewhere else in Utah, visit the Utah WIC website at wic.utah.gov to find a WIC clinic near you.

If you live outside Utah, visit the national WIC website at fna.usda.gov/wic to find services in your state.

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End of Survey

How did you hear about WIC?

Family/Friend

Outreach Program

Other...

Additional comments regarding WIC appointments?

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Property Watch

Frequently Visited Pages

DC Applications

Mailing Address

Women, Infants, and Children (WIC)

WIC Referral

Application Progress

Application Progress

Application Progress

Household Size

Income Guidelines

Application Progress

WIC Appointment Request Form

Application Progress

Mother's Demographic Information

Application Progress

Child's Demographic Information

Child 2 Demographic Information

Child 3 Demographic Information

Child 4 Demographic Information

Child 5 Demographic Information

Confirm Eligibility

Transfer Of Records

You may not Qualify

May not be eligible

End of Survey

Locations

Contact Us

SERVICES OFFERED BY DAVIS COUNTY

Property Watch

Frequently Visited Pages

DC Applications

Location

Phone

Hours

Mailing Address

Department Phones

Women, Infants, and Children (WIC)

WIC Referral

Application Progress

Application Progress

Application Progress

Household Size

Income Guidelines

Application Progress

WIC Appointment Request Form

Application Progress

Mother's Demographic Information

Application Progress

Child's Demographic Information

Child 2 Demographic Information

Child 3 Demographic Information

Child 4 Demographic Information

Child 5 Demographic Information

Confirm Eligibility

Transfer Of Records

You may not Qualify

May not be eligible

End of Survey

Locations

Contact Us