Get Proxy Signature Form

Filling out the Proxy Signature Form is essential for individuals designated to receive nutrition education and WIC food instruments on behalf of a participant, parent, or legal guardian. This guide provides step-by-step instructions to ensure a smooth online completion of the form.

Follow the steps to complete the Proxy Signature Form online

1. Click the ‘Get Form’ button to obtain the Proxy Signature Form, ensuring it opens in your document editor.
2. Print name: Enter the full name of the participant, parent, or legal guardian in the designated field.
3. Relationship to participant: Specify the relationship to the participant, such as parent or guardian.
4. Print proxy name: Input the name of the proxy who will be acting on behalf of the participant.
5. State how proxy will share nutrition education and healthcare referrals: Clearly indicate the methods through which the proxy will disseminate nutrition education information and necessary referrals. Options can include verbal communication or providing written materials.
6. Name of participant/child/infant: Fill in the name(s) of the participant(s) for whom the proxy is acting.
7. Client ID number: Enter the Client ID number associated with the participant, child, or infant.
8. Check boxes: The proxy should carefully read and check each applicable box to indicate their understanding and agreement to the responsibilities outlined.
9. Signature of proxy and date: The proxy must sign and date the form to validate their role and consent.
10. Local agency signature and date: A local agency representative will sign and date the form to confirm that the proxy has been accepted.

Complete the Proxy Signature Form online today to ensure seamless support for your WIC needs.