Form Center

By signing in or creating an account, some fields will auto-populate with your information and your submitted forms will be saved and accessible to you.

Tri-County Health Department - Request a WIC Appointment

  1. Tri-County WIC will contact families within 3-5 business days of the form submission.

  2. Use the "Google Select Language" option located at the bottom right corner of your screen to translate this form. Utilice la opción "Google Select Language" situado en la esquina inferior deracha de la pantalla para traducir esta forma.

  3. WIC_logo_green_transparent

  4. Select One*

  5. Family Member Categories*

    WIC provides services to family members in the following categories. Please select all that apply to your family.

  6. (enter clinic name)

  7. (enter how you heard about WIC)

  8. Note: Please be aware this form is not a secure method of communication. Please do not include information in this form you would like to remain confidential.

  9. (Include information that may be helpful to us such as language preference, need formula, need breastfeeding support, etc. )

  10. TCHD Website color Capture

  11. In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA. Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English. To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: (1) mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: program.intake@usda.gov. This institution is an equal opportunity provider.

  12. Leave This Blank:

  13. This field is not part of the form submission.