WIC Form

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WIC

Apply / Recertify Online for WIC at ODA - Available to all New York State Residents

Thank you for your interest in the ODA WIC program. After you submit this form, someone from ODA WIC will call you. WIC is a nutrition program for women, infants, and children < 5 years old. You can start online by completing this form. However, completing the form does not guarantee your enrollment in the program, as your eligibility will be determined when we review your information.

Residency

Do you live in New York State?

Yes

Income

Do you or anyone in your household receive Medicaid, SNAP or TANF (temporary aid to needy families)?

Yes

Contact Information

* indicates a required field.

* First name

* Last name

* Street address

* City

* State

* Zip code

* E-mail address

* Confirm e-mail address

* Mobile phone number

* Home phone number

* Date of birth

Application status

Select the option that matches your application status.

Never had WIC

Have/had WIC in New York State

Have/had WIC outside NYS within the last year

* You will need to obtain a Verification of Certification Document (VOC) from your current out-of-state WIC agency and upload it here

Applicant's information

WIC benefits are for pregnant and postpartum mothers, and childen up to the age of 5 years. Please select which you are applying for:

I am pregnant

I experienced a pregnancy loss less than 6 months ago

I have an infant less than 1 year old (applying for mother and infant)

* How is infant fed?

I have child(ren) between the ages of 1 and 5 years old

I am a foster parent of legal guardian of a child less than 5 years old

None of the above

Mother's information

Please enter information the about the WIC applicant:

* Mother's first name

* Mother's last name

* Mother's birth date

* Mother's height in inches

* Mother's weight

* Date taken

* Height, weight can also be taken at home, must be taken within the last 60 days.

Click to upload WIC form with most recent blood count (hemoglobin/hematocrit), if available. Document subject to review and approval.

* Make sure form is signed, stamped and dated by the doctor at the bottom, and your name/phone # is filled in at the top.

* Estimated due date: Enter due date or N/A

N/A

* Date of pregnancy loss

Please check all that apply (at least 1 is mandatory)

The mother has Medicaid

* Medicaid Number

The mother has SNAP (food stamp)

Upload official SNAP letter

The mother has TANF (temporary aid to needy families)

Upload official TANF letter

If the mother has any disability, please describe:

Child(ren) information

Please select the number of children applying for/renewing WIC (less than 5 years old)

Please enter information the about the child

* Child's first name

* Child's last name

* Child's birth date

* Child's height in inches

* Child's weight

* Date taken

* Height, weight can also be taken at home, must be taken within the last 60 days.

Click to upload WIC form with most recent blood count (hemoglobin/hematocrit), if available. Document subject to review and approval.

* Make sure form is signed, stamped and dated by the doctor at the bottom, and your name/phone # is filled in at the top.

Please check all that apply (at least 1 is mandatory)

The child has Medicaid

Medicaid Number

The child has SNAP (food stamp)

Upload official SNAP letter

The child has TANF (temporary aid to needy families)

Upload official TANF letter

If the child has any disability, please describe:

If your child requires special formula, please upload the document here

House income information

* Household Size: (all residing in the home)

* Name of person earning income

* How much

* How often

Additional information

Voter registration:

Already registered

I want to register to vote

Declined

Rights & responsibilities:

*I read, understood and agree to the WIC particiant rights and responsibilities. Read WIC participant rights and responsibilities

ODA Community Development, a non-profit 501c3 multi-faceted organization, provides a host of programs to the community and beyond. We cater to individualized needs, offering professional business, housing, health, nutritional, and community beautification services particularly to low-income and minority communities in New York. Our dedication is legendary.

Since our inception in 1974, we have seen incredible growth, both in number of services and the people who walk through our doors. And that makes us proud! Our hands-on approach, where we actively assist those who reach out to us and develop a close working relationship with them is but one of the many secrets to our success. ODA. Consistently building upon our tradition of excellence.

ODA Williamsburg


12 Heyward St. Brooklyn NY 11249 718.522.5620	14-16 Heyward St. Brooklyn NY 11249 718.260-4600	751 Wythe Ave Brooklyn NY 11249 718.260.4600	420 Broadway St. Brooklyn NY 11211 718.384-11211

ODA Clinton Hill

517 Park Ave.
Brooklyn NY 11205
718.260-4640

ODA Upstate N.Y.

6 Dairyland Road
Woodridge NY 12789
(845) 434-2060

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