Signature Authorization Form

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NEW YORK STATE DEPARTMENT OF HEALTH
For Office Use Only
Bureau of Supplemental Food Programs
Date Voided: ____________________________
SIGNATURE AUTHORIZATION FORM
Participant’s Initials: ______________________
Participant Name(s)
Individual WIC I.D. Numbers
________________________________________________
___________________________________________
________________________________________________
___________________________________________
________________________________________________
___________________________________________
________________________________________________
___________________________________________
________________________________________________
___________________________________________
________________________________________________
___________________________________________
There may be times when you are unable to pick up checks, shop, or attend a certification appointment. You may choose a
proxy or caretaker to represent you at these times. You are not required to have a proxy or caretaker.
Proxy:
Caretaker (can be parent or guardian):
•
•
can serve no more than two families
must be able to provide information on the eating habits
•
and medical conditions of you and/or your child
should be someone you know well and trust
•
•
can pick up your WIC Food Instruments
can pick up your WIC Food Instruments
•
•
can shop for you
can shop for you
•
•
can represent you at certification and at nutrition
cannot
represent you at certification
education sessions
Please check one of the following for the person below:
Please check one of the following for the person below:
 Proxy
 Proxy
 Caretaker/Parent/Guardian
 Caretaker/Parent/Guardian
Signature
Date
Signature
Date
Name (please print)
Name (please print)
Address
Apt. #
Address
Apt. #
City
State
Zip Code
City
State
Zip Code
Telephone #
Telephone #
It is your responsibility to instruct your proxies/caretakers in the proper use of the WIC Program. You must also notify the WIC
Program of any changes in your proxies/caretakers.
Signature of Participant/Parent/Guardian (sign only after form is completed)
Date
DOH-141 (12/98)
WIC is an Equal Opportunity Program.

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