WIC (Women, Infants, Children) Program Screen

Please answer the questions below so that we can see if there is qualification for WIC Services.

Referral Type

• Referral: *

  I'm referring myself/my child(ren)
  I'm a partner or provider referring on behalf of the client
  

Referring Provider Information

• Skip this section if this is a self referral.:
• Referring Provider Organization:
• Referring Provider Name:
• Referring Provider Phone:
• Provider Comments:

Client Information

• What is your name or the name of the person you are referring?: *
• What is your phone number or the phone number of the person you are referring?: *

Agreement and Signature

• Contact Me: *

  Yes, I understand that an employee from Jackson County Health Services' WIC Program will contact me to find out if I qualify for WIC.
• Digital Signature: *