TT RIGHTS AND RESPONSIBILITIES WIC STAFF: Verbally review this page. OMY RIGHTS = : IF qualify for WIC, I'l get a WIC Card to buy healthy foods at the grocery store. | understand WIC doesn't give all the food or formula I need for the whole month, ‘can ask for a Fair Hearing if | disagree with ‘(# Nutition Information: | will get information about ‘a decision about my WIC eligibility nutrition topics that interest me. + ate norton) con transfer to another WIC clinic Sees SASETNR ENE willhelp and supportme _I can ask WIC staff to give me transfer information, ith breastfeeding, wi information i private, WIC ony uses my | > Heath Cre infortan a Rotor WC wil oe iNomaton for recoking WIC senses, unica othoee row about immunizations finding a decte, and cther indicated in writing by the clinic services | might need, IC and store staff will treat me fairly and equally, wth courtesy and respect. By signing electronically, | agree: * Ihave read, understand, and agree to the rules and agreement on this form. * I received a copy of this form. Particjpant/Parent Guardian/Caretaker Signature. Date Participant name(s): Last, First Clinic Staff: Only have Participant/Parent Guardian/Caretaker sign the paper form when needed, for example due to computer issues or power outages. This institution is an equal opportunity provider. Washington State WIC Nutrition Program doesn't discriminate