Your Rights and Responsibilities

For the Kansas Department of Health and Environment WIC Program

I AGREE TO:

• Attend all scheduled nutrition education classes and appointments.
• Be on time for all appointments.
• Let WIC staff know in advance if I cannot keep an appointment.
• Bring proof of income, address, and identification for each person applying.
• Give the WIC staff truthful information about my or my child's medical history, my household income and the foods that I eat or my child eats.
• Have my or my child's weight, height and blood checked (finger or heel stick) and a diet assessment.
• Handle my WIC checks carefully - like they were cash.
• Call the WIC office right away if my checks are damaged, lost, or stolen. Checks are replaced only in special cases.
• Buy only WIC foods with WIC checks.
• Let the WIC staff know if my address or income changes, if I am going to move away, or if I no longer have custody of the client.

I UNDERSTAND THAT:

• WIC will give me checks to buy certain foods at WIC authorized grocery stores each month.
• WIC will provide referrals to other helpful programs and health services. I am encouraged to participate.
• I may be dropped from WIC if I participate in more than one WIC Program or a WIC and Commodity Supplemental Food Program in any one month.
• Standards for eligibility and participation in the WIC Program are the same for everyone, regardless of race, color, national origin, sex, age, or disability.
• I may appeal any decision made by the local agency regarding my eligibility for WIC. I may be dropped from WIC if I or someone with me makes changes on my WIC check; returns WIC foods for cash or non-WIC foods; sells, trades, or gives away WIC foods; buys non-WIC foods; uses an unauthorized vendor; or verbally or physically abuses WIC or vendor staff. I also may be required to repay benefits.
• My WIC records may be released to the following programs to determine eligibility or conduct outreach: Other WIC programs, Maternal & Child Health, School Health, Family Planning, Statewide Farmworker Health, Maternal and Infant, Healthy Start/Home Visitor, Immunizations, Children with Special Health Care Needs, Infant Toddler, Parents as Teachers, Kansas Childhood Lead Poisoning Prevention, Head Start, Health Wave, Commodity Supplemental Food, Temporary Aid to Families, Kansas Food Assistance, Medicaid, KAN-Be-Healthy, Dept. of Education Child Nutrition Programs, and Expanded Food Nutrition Education Programs.

I have been advised of my rights and responsibilities under the Program. I certify that the information I have provided for my eligibility determination is correct, to the best of my knowledge. This certification form is being submitted in connection with the receipt of Federal assistance. Program officials may verify information on this form. I understand that intentionally making a false or misleading statement or intentionally misrepresenting, concealing, or withholding facts may result in paying the State agency, in cash, the value of the food benefits improperly issued to me and may subject me to civil or criminal prosecution under State and Federal law.

In accordance with Federal law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. To file a complaint of discrimination, write USDA, Director, Office of Adjudication and Compliance, 1400 Independence Avenue SW, Washington, D.C. 20250-9410 or call (800) 795-3272 (voice) or (202) 720-6382 (TTY). USDA is an equal opportunity provider.