Get Wic Proxy

N EW YORK 5TATE DEPARTMENT OF H EALTH Authorization Form Division of Nutrition/WlC Program If you would like to authorize another person to represenl you at times when you are unable to attend WIC appointments or redeem food instruments please check either Parent/Spouse/Partner Representative or Proxy. You are allowed to have up to two persons to ForOffice Use Only Validation Date represent you but this is not required. Void Date This form does not allow for the release of WIC records. Participant s Initials Participant Name sl lndividuat WIC ID Numbers. has the same rights under the WIC program as Representative the enrolting parent/spouse/partner can authorize a Representative or Proxy. Can sign all required forms. can represent you at your chitdren s certification appointments. can pick up and redeem yourfood instruments can sign a required forms appoi ntments a must be someone responsibte forthe primary care ofthe participant and able to provide information on the eating habits and medicaI condition of the nutrition education appointments D Proxy I have instructed the above authorized parent/spouse/partner representative or proxy on the rules and regulations ofthe WIC program including proper use of food instruments at redemption locations. I understand that I am tiabte for improper or fraudutent use of the WIC program by said person. Signature of Participant/Parent/Guardia D0H-141 12109 sign onty after form is completed Date. You are allowed to have up to two persons to ForOffice Use Only Validation Date represent you but this is not required* Void Date This form does not allow for the release of WIC records. Participant s Initials Participant Name sl lndividuat WIC ID Numbers. has the same rights under the WIC program as Representative the enrolting parent/spouse/partner can authorize a Representative or Proxy. can sign all required forms. can represent you at your chitdren s certification appointments. can pick up and redeem yourfood instruments can sign a required forms appoi ntments a must be someone responsibte forthe primary care ofthe participant and able to provide information on the eating habits and medicaI condition of the nutrition education appointments D Proxy I have instructed the above authorized parent/spouse/partner representative or proxy on the rules and regulations ofthe WIC program including proper use of food instruments at redemption locations. I understand that I am tiabte for improper or fraudutent use of the WIC program by said person* Signature of Participant/Parent/Guardia D0H-141 12109 sign onty after form is completed Date. Participant s Initials Participant Name sl lndividuat WIC ID Numbers. has the same rights under the WIC program as Representative the enrolting parent/spouse/partner can authorize a Representative or Proxy. can sign all required forms. can represent you at your chitdren s certification appointments. can pick up and redeem yourfood instruments can sign a required forms appoi ntments a must be someone responsibte forthe primary care ofthe participant and able to provide information on the eating habits and medicaI condition of the nutrition education appointments D Proxy I have instructed the above authorized parent/spouse/partner representative or proxy on the rules and regulations ofthe WIC program including proper use of food instruments at redemption locations.