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Participant Demographics Screen (fill out one page for each participant) Identity Information Last Name: _____________________________________ First Name: ______________________________________ M.I. ________ Proof of ID: _____________________________________ SSN: ___________________ DOB: ___________ WIC Category: ________

Gender: Male Female

Foster Child Yes No

Foster Care Entry Date: ___________________ or Date unknown

Proof of Foster Care: ________________________

Race/Ethnicity Declared Observed Ethnicity: Non-Hispanic Hispanic (Circle one)

Race (Circle all that apply): American Indian or Alaskan Native / Asian / Black or African American / White / Native Hawaiian or Pacific Islander

Physical Presence:

Yes

No Physical Presence exception reason: ______________________________________________________________________________ Immunization Consent:

Yes

No Special Needs: (Circle all that apply) Forms assistance Hearing impaired Mentally Challanged

Physically Disabled

Visually Impaired Speech impaired Wheelchair access

Reading assistance

Other: __________________________________________________________________

Income Screen Family Size ________________________ No. of Expected Infants ______________ Total Family Size ___________________

Family – Adjunct Participation _________________________________________________________ SNAP Medicaid

TANF Participant _________________________________________________________ SNAP

Medicaid

TANF Participant _________________________________________________________ SNAP

Medicaid

TANF Participant _________________________________________________________ SNAP

Medicaid

TANF Participant

Self-Declared Income _________________________ or Self-Declared Income Range ________________________

Income Details __________________ __________________ ______________________ ____________________ _________________________ Source Proof

Frequency

Amount

Duration __________________ __________________ ______________________ ____________________ _________________________ Source Proof

Frequency

Amount

Duration __________________ __________________ ______________________ ____________________ _________________________ Source Proof

Frequency

Amount

Duration

Zero Income Declaration Reason _________________________________ Comparison Frequency ___________________________

Total Income: ______________________________________* Remember: Foster children have their own income documentation

Issue EBT Card Screen Select Cardholder _____________________________________________________________________________________________

Card Number __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ (Card should be 16 digits long. Double check number.)

Certification Signature Parent/Guardian will sign a hard copy of the Rights and Responsibilities. This document must be scanned in later. 37433_WIC_Ctad_FIN2.indd 10 37433_WIC_Ctad_FIN2.indd 10 7/31/20 3:00 PM 7/31/20 3:00 PM