Wic Authorized Representative Letter printable pdf download

Wic Authorized Representative Letter

WIC Authorized Representative Letter

If you are not able to be present at the WIC eligibility appointment, you may have an authorized

representative act on your behalf by completing the following letter.

__________________________

(Date)

Dear WIC Project Staff,

I give permission for _____________________________ to bring my children to the WIC clinic.

(Name of Authorized Representative)

This permission is for: ___ Today’s WIC appointment only, or

___ Any WIC appointments during the next six months.

My children’s full names are: _____________________________________________________

______________________________________________________________________________

I understand that my children will have measurements such as height and weight taken and may

have a finger stick to check blood iron level.

I have provided my authorized representative with the required forms, checked below, signed as

needed, and told my representative what to expect at a WIC appointment. If you have any

questions, please call me at this telephone number: _________________________________.

Required Forms

____ The Ohio WIC Application form (signed)

____ Welcome to WIC Letter (signed)

____ Health History form

____ Proof of:

___ Identity (some examples: driver’s license, WIC ID card, crib card, birth certificate,

shot record Medicaid card, Ohio ID)

___ Residence (some examples: utility or other bill, WIC Appointment reminder,

driver’s license)

___ Income (some examples: three pay stubs, proof of receiving public assistance,

retirement benefits, tax forms)

____ Immunization records

____ Voter Registration Form (signed)

Sincerely.

______________________________________________

Parent or Guardian Signature

USDA is an equal opportunity provider and employer

PPL 180

Wic Authorized Representative Letter