La Crosse County WIC Online Application

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To find out if you qualify, complete this application and submit. Our WIC Program will be in touch with you.

If you do not hear from us within ten days, please call 608-785-9865.
Calls also welcome to ask about eligibility or to make an appointment.
Email: laxwic@lacrossecounty.org.
Address: La Crosse County WIC Program, 300 4th Street North, La Crosse, WI 54601.
https://www.getactivelacrosse.org/eat-healthy/women-infants-and-children/

USDA is an equal opportunity provider and employer.
Please find the full non-discrimination statement at:
https://www.dhs.wisconsin.gov/wic/non-discrimination.htm#english

Answer the following questions to the best of your knowledge. All information will be kept confidential.

Your First and Last Name *

Your Date of Birth *

YYYY

Cell Phone Number

Home Phone Number

What is your preferred method of communication? *

Phone/Voice Message

Text Message

Address Street *

City *

Zip Code *

County *

Are you pregnant? *

Yes

Have you had a baby in the last 6 months? *

Yes

Number of children in the home under 5 years old? *

What is the total number in the home? (including baby if pregnant) *

Is anyone in the home receiving BadgerCare?(used to screen for eligibility) *

Yes

What is the current household income? Enter dollar amount under "Other"(used to screen for eligibility) *

No Current Income

Weekly (enter $ amount under other)

Bi-Weekly (enter $ amount under other)

Monthly (enter $ amount under other)

Yearly (enter $ amount under other)

Other:

Required

Submit

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