Plattsburgh, NY

                                                                                                                                                                         

WIC FORMS

               


Downloadable WIC Forms

 To print a form, click on it and select 'Print' from the 'File' menu or click on the Acrobat print icon.

Instructions: Print all appropriate forms and send to:

Clinton County Health Department
Nutrition Unit
133 Margaret Street
Plattsburgh, NY 12901

If you have any questions, please call us at (518) 565-4830.
 

                          
 


Prenatal Woman's WIC Application

Income Form 
Prenatal Woman Medical Form
Prenatal Woman - Diet Questionnaire
 

Breastfeeding Woman's WIC Application

Income Form
Breastfeeding Woman Medical Form
Breastfeeding Woman - Diet Questionnaire


Non-Breastfeeding Woman's WIC Application

Income Form
Non-Breastfeeding Woman Medical Form
Non-Breastfeeding Woman - Diet Questionnaire


 
Infant Birth to 4 Months WIC Application

Income Form
Infant Medical Form
Infant Birth to 4 months Questionnaire


Infant 4 Months to 12 Months WIC Application

Income Form
Infant Medical Form
Infant 4-12 months Questionnaire


Children Up to Age 5 WIC Application

Income Form
Child Medical Form
Child - Diet Questionnaire


Other Forms

WIC Proxy Authorization Form
Request for Formula Changes Form
 

                                                                                                                                                             

           Note:  These are external web links.

Clinton County does not discriminate on the basis of race, color, national origin, sex, sexual orientation, religion, age or disability in employment or the provision
of services. The information on the Clinton County Health Department website is for educational purposes only. Nothing on the pages of this site shall be construed
as medical, fitness, dietetic, or other professional advice. This information is based on current beliefs among researchers and research studies published in the
current scientific literature. Clinton County is not responsible for, nor does it necessarily endorse any content on external web links.

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