WIC Forms

When you participate in WIC, staff will ask you for some information. Some forms are required to participate. WIC staff will let you know if you need to fill out any of these forms.

Do you want to do your WIC appointment from home instead of coming into Adelante Healthcare?
Please contact us at 1.877.809.5092 for more information.

Adelante WIC Patient Forms

WIC Rights and Responsibilities

WIC Rights and Responsibilities Spanish

Voter Registration

Pump Loan Agreement

Statement of Documentation

Statement of Documentation Spanish

Change of Authorized Rep

Change of Authorized Rep Spanish

Language Access Waiver

Language Access Waiver Spanish

Notice of Ineligibility

Notice of Ineligibility Spanish

Proxy Certification

Proxy Certification Spanish

AZ Referral & physical presence Exemption Form

 

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In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.

Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.

To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: How to File a Complaint, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:

mail: U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
Washington, D.C. 20250-9410;
fax: (202) 690-7442; or
email: program.intake@usda.gov

This institution is an equal opportunity provider.