WIC Participant Rights, Responsibilities and Consent – English
Participant Rights, Responsibilities and Consent
Please choose if you do or do not give permission for the following:
You may review your record and have the right to cancel consent in writing at any time.
The taking of height and weight measurements and a finger stick blood test to check iron status for myself and/or my child(ren). These are used to establish nutritional need for the WIC Program.
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Yes
No
The WIC Program to share eligibility information (such as name, address, income level and birthdate) for myself and my child(ren) with local, state, and federal WIC programs. This information may also be shared with the Idaho Department of Health and Welfare’s Medicaid and SNAP programs for the purpose of referral.
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Yes
No
The WIC Program to share immunization status with the Immunizations Program for referral purposes.
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Yes
No
The WIC Program to schedule remote or virtual appointments when possible, such as video or phone options offered by the clinic. I understand that I can opt out and come to the clinic for these appointments at any time.
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Yes
No
The WIC Program to contact me and leave messages at the phone number provided. I understand messages left on my phone may contain information such as the WIC program name, applicant , participant and/or family name(s) and information related to appointments. I understand I can notify the clinic and change my choice about WIC contacting me at any time.
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Yes
No
Please read the statements and check the box below to approve your understanding of the following:
I have been advised of my rights and obligations under the program.
I understand my rights and responsibilities and I agree to follow them.
I understand that I am responsible for the use and behavior of my second cardholder, if applicable.
I understand the WIC program uses health data and eligibility information for receiving WIC services and for evaluating the success of the program, monitoring, and auditing the program. I release the Idaho Department of Health and Welfare from any and all responsibility and liability concerning the release of information I have consented to be released.
I certify that the information I have provided for my eligibility determination is correct to the best of my knowledge.
All application information submitted is connected to the receipt of federal assistance. Program officials may verify application information.
I understand that intentionally making a false or misleading statement or intentionally misrepresenting, concealing, or withholding facts may result in paying the state agency, in cash, the value of the food benefits improperly issued to me and may subject me to civil or criminal prosecution under state and federal law.
Affirmation
As the first cardholder, I have read, understand and agree with the statements above.
On behalf of the first cardholder, I have read, understand and agree with the statements above.
First Cardholder Name
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First Cardholder Name
First Name
First Name
Last Name
Last Name
Staff Name for Acknowledgement
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Staff Name for Acknowledgement
First Name
First Name
Last Name
Last Name
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First Cardholder Signature
This institution is an equal opportunity provider.
FORM 104A 5/2025
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