North Carolina WIC Families - Referral Form

WIC is the Special Supplemental Nutrition Program for Women, Infants, and Children funded by the United States Department of Agriculture. It is commonly referred to as the WIC Program. County health departments, community and rural health centers, and community action agencies provide WIC Program services. WIC provides nutrition education, breastfeeding support, healthy food, health referrals and other services free of charge to North Carolina families who qualify. The WIC Program promotes healthy habits and healthy families to pregnant, breastfeeding and postpartum women, infants and children until age 5.

After filling out and submitting this form, a WIC clinic near you will contact you within 20 days though typical response time is much sooner.

Back to: WIC Eligibility and Food Benefits | MyWIC

An asterisk * indicates the field is required.

*First Name:

If you can see this field, leave it blank:

*Last Name:

*Phone Number:

*County of Residence or Preferred WIC Agency:

Select a county Alamance Alexander Alleghany Anson Ashe Avery Beaufort Bertie Bladen Brunswick Buncombe Burke Cabarrus Caldwell Camden Carteret Caswell Catawba Chatham Cherokee Chowan Clay Cleveland Columbus CommWell Health Craven Cumberland Currituck Dare Davidson Davie Duplin Durham Eastern Band of Cherokee Indians Edgecombe Forsyth Franklin Gaston Gates Graham Granville Greene Guilford Halifax Harnett Haywood Henderson Hertford Hoke Hyde Iredell Jackson Johnston Jones Lee Lenoir Lincoln Lincoln Community Health Center Macon Madison Martin McDowell Mecklenburg Mitchell Montgomery Moore Nash New Hanover Northampton Onslow Orange Pamlico Pasquotank Pender Perquimans Person Piedmont Health Services Pitt Polk Randolph Richmond Robeson Rockingham Rowan Rutherford Sampson Scotland Stanly Stokes Surry Swain Transylvania Tyrrell Union Vance Wake Warren Washington Watauga Wayne Wilkes Wilson Yadkin Yancey

*Category:

Select a category Pregnant Postpartum Breastfeeding Infant/Child Until Age Five

*Preferred Language:

Select your preferred language English Spanish Arabic Chinese French Korean Vietnamese

*Heard about WIC / Referred By?

Select a referral source Billboard Advertisement/Campaign Doctor/Health Care Provider ePASS Food and Nutrition Services (Food Stamps) Food Bank/Food Pantry/Meal Program Friend or Family Member Head Start Program/Child Care Center Hospital Medicaid/NC Health Choice (CHIP) NCCARE360 Radio Advertisement Self Social Media/Social Marketing TV Advertisement Other

 

 

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The information submitted on this form is confidential. For help with this form email or phone Nan Pardington, 919-707-5782.