Kenosha WIC

WIC Pre-Application:

 

Contact Information
 

First Name:*
Last Name:*
Address Line 1:
Address Line 2:  
City:   
State:  Wisconsin 
Zip Code:   
Email:   
Best Number to Reach You:*  (xxx) xxx-xxxx  
   

 

Household Income Information

 

Number of People in your Household:
Include any unborn babies  
Household Income Before Taxes: $
Include Child Support, grants and scholarships  

 

Income Time Frame:   Per Week    Per 2 Weeks     Per Month     Per Year


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2113 North Wisconsin Street Racine, WI 53402 | 262-637-8377
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