WIC Qualification Form Answer the following questions to the best of your knowledge. All information will be kept CONFIDENTIAL. Name Street Address PO Box City State Zip Code Email Email Confirm Number of people in your family (including yourself) 1 2 3 4 5 6 7 8 9 10 11 12 Household Income Income Frequency Weekly Bi-Weekly Monthly Annually Are you pregnant? Yes      No If pregnant, when is your due date? Have you had a baby in the last six months? Yes      No Are you breastfeeding a baby who's under one year of age? Yes      No Please complete the following information for each child under the age of five: First Child Name: Sex: Male      Female Birthdate: Second Child Name: Sex: Male      Female Birthdate: Third Child Name: Sex: Male      Female Birthdate: Fourth Child Name: Sex: Male      Female Birthdate: Fifth Child Name: Sex: Male      Female Birthdate: