WIC Referral Form

Champaign Urbana Public Health District

Last name

Establishment information

Referring Agency *

Referring professional *

Agency phone

Parent/guardian information

Parent/guardian name *

Parent/guardian DOB *

Phone number *

Email address *

Preferred language *

Address *

City *

State *

Zip code *

Childen information

Child 1 name *

Child 1 DOB *

Child 2 name

Child 2 DOB

Child 3 name

Child 3 DOB

Child 4 name

Child 4 DOB

Child 5 name

Child 5 DOB

Child 6 name

Child 6 DOB

Additional information

Preferred clinic *

Champaign Rantoul Orchard Downs

Feeding choice *

Breast Milk Formula Both

Additional comments

Application date

I give my permission to provide WIC with the above information
Le doy mi permiso a WIC para proporcionar la información anterior
J'autorise à fournir à WIC les informations ci-dessus

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Referred parent / guardian will be contacted within two business days from referral. For urgent referrals, please follow up with a phone call to our Champaign office, Monday-Friday, 8:30 a.m. - 12:00 p.m., 1:00 p.m. - 4:30 p.m. Our phone number is 217-531-4529. Thank you!