CITIZEN POTAWATOMI NATION WIC PROGRAM
Applicant information: (Circle One)
Please fill out this for PREGNANT/ BREAST FEEDING/ POSTPARTUM WOMAN/ INFANT/CHILDapplying for WIC.
NAME: (Last)______(First)______(MI)______
Address: ______City______Zip______
*Directions to home if address is a PO BOX, RR, or NBU:
*______
Date of Birth: ______/______/______Gender: (circle) Male/Female **SS#______/______/______
Phone (home): (______) ______-______(work): (______) ______-______Parent’sname(ifchild’s application) ______
Ethnic (circle one): Hispanic/Latino or Non Hispanic/Latino
Race: (circle all that applies): White/Black/Asian/Alaskan Native/Native Hawaiian or Pacific Islander/or American Indian:
Tribal affiliation: ______
Last grade completed in school: (woman or parent of child) ______
If you are currently receiving any of the following benefits, you meet the Income Guidelines for the WIC Program: (check all that applies)
(A) Do you receive TANF? (Temporary Assistance for Needy Families) YES_____NO_____ if yes: TANF $$$ Amount ______
(B) Is anyone in your household receiving Medical Assistance through DHS? YES_____NO_____
(C) Are you currently enrolled in the Food Stamp Program? YES_____NO_____ if yes: Food Stamp $ Amount ______
(D) Are you enrolled in the Commodity Food Program? (FDPIR) YES_____NO_____
(E) Are you enrolled in any other WIC Program besides this one? YES_____NO_____ Total adjunct income $______(office use only)
How many living in the home?______
List ALL Household Members: (if more than 7, attach additional sheet if needed)
Name of Household Members Employed? Employer $ Gross Amount How often paidTotal $ Amount
(Before Taxes) (Weekly,Bi-weekly,Monthly,etc.) (Office use only)
______Yes No ______
______Yes No ______
______Yes No ______
______Yes No ______
______Yes No ______
______Yes No ______
______Yes No ______
Does any Household member have any other income? (Such as child support, Social Security, Unemployment, etc.)
YES_____ NO_____if yes, complete below:
Name of person receiving incomeType of income $ Gross Amt. How often received Total $ (office use only)
______
______
______
Grand Total $ ______
(Office use only)
The USDA prohibits discrimination in its program on the basis of race, color, national origin, sex, age and disability. To file a complaint, write USDA, Director, Office of Civil Rights, 1400 Independence Ave., SW, WashingtonD.C.20250-9410 or call (800)795-3272 (voice) or (202)720-6382 (TTY). USDA is an equal opportunity provider and employer.
*RIGHTS: You may appeal any decision made by the agency regarding your eligibility for the program.
*The local agency will make referrals and nutrition education available to you and you are encouraged to participate in these services.
Responsibilities- *I will buy only those foods allowed on the WIC vouchers. *I will not accept cash or credit for my vouchers. *I will be polite to all WIC clinic and staff. *If I threaten or do harm to the staff, I may be dropped from the program. *I will not participate in any other WIC Program. *I will pick up vouchers each month at the appointed time. If I fail to pick vouchers for two consecutive months, I will be dropped from the program.
I have been informed of my rights and responsibilities. The facts that I have given are true to the best of my knowledge, and you may check them. WIC is a Federal Program and I may be prosecuted if I have liedmay result in paying the State agency, in cash, the value of the food benefits improperly issued to me. I also hereby release any medical information about myself or my child that is necessary for participation in this program. **Provisions of the Social Security number is voluntary. It will be used for the purpose of verifying eligibility and the detection of dual participation. It will not be shared with third parties.
______Participant’s ID#
Signature of Participant, Parent, GuardianDate (office only)
***********************************CITIZEN POTAWATOMI NATION CERTIFICATION****************************************
Name: ______DOB: _____/_____/_____ Date Measured _____/_____/_____ Age: ______
Height: ______Weight: ______Hgb: _____.____ Hct: _____% EDC: _____/_____/_____ Pre-pregnancy Wt: ______
Ht./Age: ______%Wt./Age: ______%Wt./Ht. ______%BMI ______
WIC Mom ? YES/NOMonths on WIC: ______(1-9)Birth Height: ______Birth Weight: ______# _____oz.
Feeding Method: (circle one) Breastfed/Formula/Breastfed and Formula
Medical Comments:
RISK CODES/PRIORITY
I CERTIFY THAT I HAVE PROPERLY SCREENDED THE PARTICIPANT FOR NUTRITIONAL RISK AND THE RISK FACTORS LISTED ABOVE ARE CORRECT.
Authorized Medical Signature: ______Title: ______Date: ______
FOR WIC OFFICE USE BELOW THIS LINE
Initial Request Date: ______/______/______Cert. Date: ______/______/______Date Cert. Expires: ______/______/______
Priority: ______Food Package: ______Proof: Identity: ______Residence: ______Physical Presence: ______
SERVICE: (Service received = “X” referrals made = “R”) ______Meets the WIC Income Eligibility Guidelines
______Exceeds the Income Guidelines (ineligible)
______WIC______Alcohol Treatment
______TANF______BIA/Social Service
______Medical Assistance______Commodity Foods I certify that I have properly screened the participant for
______Food Stamps______Employment income eligibility and informed the participant of fair
______Child Support______Head Start/Early Child. Ed. hearing rights and responsibilities.
______Family Planning______Social Security
______Immunization______Tribal Health
______PHS OB Program
______PHS Well Child ______
Authorized SignatureTitle Date