Colorado WIC Families - Referral Form
The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides nutrition education, breastfeeding support, healthy food, health referrals and other services free of charge to Colorado families who qualify. WIC’s goal is to help keep pregnant and breastfeeding women and children under age 5 healthy.
By filling out this form, a WIC clinic near you will contact you soon.
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In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating on the basis on race, color, national origin, sex (including gender identity and sexual orientation), disability, age, or reprisal or retaliation for prior civil rights activity. Program information may be made available in languages other than English. Persons with disabilities who require alternative means of communication to obtain program information (e.g. Braille, large print, audiotape, American Sign Language), should contact the responsible state or local agency that administers the program or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339. To file a program complaint of discrimination, a Complainant should complete a Form AD- 3027, USDA Program Discrimination Complaint Form which can be found online at: https://www.usda.gov/sites/default/files/documents/USDA-OASCR%20P-Complaint-Form-0508-0002-508-11-28-17Fax2Mail.pdf , from any USDA office, by calling (866) 632-9992, or by writing a letter addressed to USDA. The letter must contain the complainant’s name, address, telephone number, and a written description of the alleged discriminatory action in sufficient detail to inform the Assistant Secretary for Civil Rights (ASCR) about the nature and date of an alleged civil rights violation. The completed AD-3027 form or letter must be submitted to USDA by:
(1) mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, SW Washington, D.C. 20250-9410; or (2) fax: (833) 256-1665 or (202) 690-7442; or (3) email:program.intake@usda.gov. This institution is an equal opportunity provider.
NOTICE: The content on this Colorado WIC form is primarily provided in English. We are providing
the Google Translate tool on this form to assist visitors with accessing information on the form in other
languages. Google Translate is a free, automated service that relies on data and technology to provide
its translations. The Google Translate feature is provided for informational purposes only. Translations
cannot be guaranteed as exact or without the inclusion of incorrect or inappropriate language. Colorado
WIC assumes no liability for any loss or damage resulting from the translations obtained through Google
Translate. If you do not understand the translated information and need additional help, please contact
your local WIC clinic.
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