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WIC FARMERS MARKET NUTRITION PROGRAM ELIGIBILITY APPLICATION

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WIC Participant First Name:

Middle Name:

WIC Participant Last Name:

Date of Birth:

Did you receive farmers market benefits last year?

What county do you currently receive WIC benefits?

Email:

Phone:

Please check here to acknowledge that you or your child currently receive WIC benefits in Mississippi.

Please check here to acknowledge that the participant understands Mississippi WIC Farmers Market Nutrition Program benefits are only redeemable at authorized farmers market and farmstand locations in the following counties: Attala, Desoto, Forrest, Harrison, Hinds, Holmes, Jones, Lafayette, Leflore, Lowndes, Marshall, Panola, Pike, Pontotoc, and Tate. In addition, benefits are available on a first-come, first-serve basis.

Use of Information

The information provided is confidential and will be used to determine your eligibility for WIC Farmer's Market benefits. Confidential information will only be shared with MSDH WIC and MDAC Farmer's Market Nutrition Program staff. Data may also be used for reporting and/or auditing.

Release of Information

Submission of electronic information is at will via email, internet, etc. although these methods may not be secure. This institution is an equal opportunity provider. Click here for WIC Non-Discrimination Statements

I consent and agree that I am sharing private information with MDAC-MSDH WIC Farmer's Market Nutrition Program.

If you do not provide your consent, you may call your local WIC clinic to apply.