WIC Program Referral Form

I am currently pregnant? *

I have a child between the ages of birth up to 5 years of age? *

I am a foster parent to a child between the ages of birth up to 5 years of age? *

I live in Fayette County? *

I am interested in knowing more about WIC and consent to a WIC official contacting me? *

I receive Medicaid? *

Name of Individual filling out the form: *

First

Last

Telephone # *

Preferred Language:

Name *

Date / Time *

child Language: Time

Comments:

We look forward to talking to you about our program! If you have any questions, please call 859-288-2483.

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