WIC Web Referral | Washington County Forms

< Return to Washington County, Oregon main site

WIC Web Referral - Sign Up Form

Please answer the questions below so that we can see if there is qualification for WIC Services. The information reported will be kept confidential.

Referral Type

I'm referring myself/my child(ren)

I'm a partner or provider referring on behalf of the client

I'm a foster parent

Name of Partner or Provider

I'm referring through Connect Oregon

Yes

Self/Parent/Guardian First Name

Self/Parent/Guardian Last Name

Full Legal Name (if different)

Pronouns (she, he, they, etc.)

Self/Parent/Guardian Date of Birth

Please enter date in format 00/00/0000

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Phone Number

Preferred Language

WIC Location

Which WIC location works best for you?

How did you hear about WIC?

Notes

Are You Pregnant?

Yes

Estimated Due Date

Do You Have Children Under the Age of 5?

Yes

How are you feeding your baby?

Child 1 - First Name

Child 1 - Last Name

Child 1 - Date of Birth

Please enter date in format 00/00/0000

Child 2 - First Name

Child 2 - Last Name

Child 2 - Date of Birth

Please enter date in format 00/00/0000

Child 3 - First Name

Child 3 - Last Name

Child 3 - Date of Birth

Please enter date in format 00/00/0000

Contact

Yes, I understand.

I understand that an employee from Washington County Health Services' WIC Program will contact me to find out if I qualify for WIC.

Signature

Please sign below.