Form Hea 4460 - Wic Program Application - Ohio Department Of Health
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1
2Ohio Department of Health
WIC Program Application
Please answer all questions on this page.
A.
Parent, guardian or applicant’s name
*
*
*
Telephone
Home
Work
Cell
*
Leave message
City
State
ZIP
County
Street address
Mailing address (if not the same as street address)
City
State
ZIP
In the section below please list everyone who is living in your home, including yourself.
B.
Relationship to you
Date of birth
*
1.
Full name—first, middle, last
Female
/
/
SELF
*
Male
*
*
*
Hispanic/Latino
If pregnant: number of
Due date
American Indian/Alaskan Native
Asian
White
unborn babies
/
/
*
*
*
*
Native Hawaiian/Other Pacific Islander
Black/African American
Yes
No
2.
Full name—first, middle, last
Relationship to you
Date of birth
*
Female
/
/
*
Male
*
*
*
Hispanic/Latino
If pregnant: number of
Due date
American Indian/Alaskan Native
Asian
White
unborn babies
/
/
*
*
*
*
Native Hawaiian/Other Pacific Islander
Black/African American
Yes
No
3.
Full name—first, middle, last
Relationship to you
*
Date of birth
Female
/
/
*
Male
Hispanic/Latino
If pregnant: number of
Due date
*
*
*
American Indian/Alaskan Native
Asian
White
unborn babies
*
*
/
/
Yes
No
*
*
Native Hawaiian/Other Pacific Islander
Black/African American
4.
Full name—first, middle, last
Relationship to you
*
Date of birth
Female
/
/
*
Male
Hispanic/Latino
*
*
*
If pregnant: number of
Due date
American Indian/Alaskan Native
Asian
White
unborn babies
*
*
Yes
No
/
/
*
*
Native Hawaiian/Other Pacific Islander
Black/African American
5.
Full name—first, middle, last
Relationship to you
Date of birth
*
Female
/
/
*
Male
Hispanic/Latino
*
*
*
If pregnant: number of
Due date
American Indian/Alaskan Native
Asian
White
unborn babies
/
/
*
*
Yes
No
*
*
Native Hawaiian/Other Pacific Islander
Black/African American
6.
Full name—first, middle, last
Relationship to you
*
Date of birth
Female
/
/
*
Male
If pregnant: number of
Hispanic/Latino
Due date
*
*
*
American Indian/Alaskan Native
Asian
White
unborn babies
*
*
/
/
Yes
No
*
*
Native Hawaiian/Other Pacific Islander
Black/African American
C.
If anyone in your home is pregnant, is she under a doctor’s care?
If yes, what is the doctor’s name?
*
*
Yes
No
D.
Has anyone in your home had a pregnancy that ended within the last six months?
If so, who?
*
*
Yes
No
E.
Is anyone in your home breastfeeding a baby less than 12 months old?
If so, who?
*
*
Yes
No
F.
Please check Yes or No if anyone in your home is receiving any of the following:
*
*
*
*
*
*
Yes
No
Ohio Works First Cash
Yes
No
Medicaid
Yes
No
Food Assistance
If so, who?
If so, who?
If so, who?
For each person in your home who has any income such as wages, self-employment, unemployment, SSI, Social Security, VA pension, workers
.
compensation, alimony, child support, lump-sum payments, please complete the lines below
Name
Name of income source
Gross amount
How often received
$
$
$
Important! You must sign the back of this application form.
HEA 4460 (Rev. 12/15)
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