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WIC Referral Form
Please select one:
I am interested in WIC
I am a referring organization
Submitter First Name
Submitter Last Name
Date of Birth
Please enter DOB in this format mm/dd/yyyy
Parent/Guardian (if applicable)
Please enter first and last name.
Maay Maay/Mai Mai
Was pregnant less than 6 months ago
Under age 5 or has children under the age of 5
Needs breast feeding support
Other Referral Information
Attachment is optional. You may attach additional information or submit a file with multiple referrals.
Attachment is optional. You may attach additional information pertaining to the client or submit a file with multiple referrals.
If you experience issues with this form, please call 503-988-3503
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