CTWIC Interest Form

If you have children (including foster children) between the ages of 0 and 5 who are applying for WIC, please list their full names (first, middle, and last):

Please provide the best phone number where we can reach you. *

What is your preferred communication method? *

Phone
Text
Email

Email Address

What is your preferred language? We will do our best to accommodate your language needs*

Other*

Do you need a sign language interpreter or a language translator? This would be a FREE service.*

Yes, a sign language interpreter
Yes, a language translator
Not needed

Please select the WIC office that is most convenient for you. This office will reach out to you to complete your application. Don't worry, you can always change your assigned location later! Click here to see a bigger map: https://tinyurl.com/ctWICoffices*

Have you ever applied for WIC before, or are you currently on WIC? (If no, skip the next question )*

Yes
No

State

City

Anything else you want us to know about your Connecticut WIC application? Please list any accessibility or accommodation requests.

How did you hear about Connecticut WIC?

How easy was this form to fill out?

Very hard
1
2
3
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5
Very Easy

What would you change, if anything, about this form?

DEPARTMENT OF PUBLIC HEALTH

DPH Submissions System

Connecticut Women, Infants, and Children (Connecticut WIC) Interest Form

* - Required Field