Refer Someone

Refer Someone New

Agency/ organization name

Referred by name

Agency email address

Did agency deliver WIC orientation?

Yes

No

Parent's name

First

Last

Parent's date of birth

Is the parent pregnant?

Yes

No

Enrolled in MediCal?

Yes

No

Parent's Medi-Cal number (if applicable)

Address

City

State/Province

Zip/Postal

Address

Child's name

First

Last

Child's date of birth

Child's Medi-Cal number (if applicable)

Monthly income (if known)

Does the parent speak English?

Yes

No

Preferred language:

Preferred contact method

Phone number

If this is not the parent's direct number, please write whose it is in this field next to the phone number

Email address

If this is not the parent's direct email, please write whose it is in this field next to the email address

Other notes/ comments

Permission for WIC to contact them?

Yes

No

This agreement to release personal information will begin on July 1, 2023 and will end on June 30, 2024.

Yes I, the parent/guardian, consent

If you are human, leave this field blank.