CONSENT TO SHARE INFORMATION

In order to better serve you, we use third party automated messaging systems to contact you about your WIC appointments and other important WIC information. We need permission from you in order to send these messages. Your information will be protected and will never be shared or used for any other purpose.

I give my permission to the WIC Program to share name, date of birth, phone number and/or email address for all members of my household eligible for WIC.

This information will be shared with the following third party service providers:

• One Call Now (automated calls, texts, emails)
• Survey Monkey (online surveys)
• Constant Contact (automated emails)

I understand that my choice to sign or not sign this form will NOT affect my eligibility for or participation in the WIC Program, or the eligibility for or participation in the WIC Program of any children for whom I am legally responsible.

I understand that depending on my phone plan, there may be charges I will be responsible for.

I understand that this agreement is effective for twelve months from the date I sign it and that I may cancel this agreement at any time by submitting a written cancellation notice to the WIC local agency.

Please only check one box below.

Yes, I give permission for WIC to contact me with appointments and messages using automated systems.

No, I do NOT give permission for WIC to contact me with appointments and messages using automated systems.

I acknowledge that I have read and agree to the above terms and conditions.

First & Last Name (required)

Family ID Number (required)

Telephone Number

Email Address

What is your preferred method for receiving communications from WIC?

 

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