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, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.
Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.
To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter 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;
(2) fax: (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.
© 2020 Colorado Department of Public Health and Environment
