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2. 
4. Get Started Online

   It only takes a few minutes to start your application online. After you submit your form, a team member from our WIC office will contact you to set up your first appointment if you are eligible. If you have more immediate needs, please call us at 785-229-3534.

6. Your First Name:*
7. Your Last Name:*
9. Your Date of Birth:*
10. If you are currently pregnant, please list your due date:
    If you are currently pregnant, please list your due date:
12. Address*
13. City*
14. State*
    -- Select One --KansasOther (if other; you are not eligible)
15. Zip*
17. Email
18. Phone Number*

    Please enter the best number to reach you. 

20. Check all that apply:*

    1. I am pregnant
    2. I am currently breastfeeding
    3. I have an infant under 6 months and don't breastfeed
    4. I have an infant under age 1
    5. I have an infant under age 5
    6. I am a foster parent of a child under age 5
21. Do you or any of your family members have access to any of the following resources?*

    Check all that apply.

    1. Medicaid
    2. TANF
    3. Snap
    4. No; I do not have any of these resources.
23. How did you hear about WIC?

    1. Doctor's Office
    2. Friend/Family Member
    3. Internet Search
    4. Social Media
    5. WIC Participant
    6. Other
Leave This Blank:


25. 1. Receive an email copy of this form.
26. Email address

    This field is not part of the form submission.

27. Submit

* indicates a required field