WIC Interpreter Waiver - English f03364

Department of Health Services Division of Public Health State of Wisconsin

Division of Public Health

F-03364 (02/2025)

WIC Family ID number

Name(s) of WIC applicant(s)/participant(s)*

It is your choice whether to complete this form. If you do not sign this form, the WIC Program will provide an interpreter during the WIC appointment.

I understand that the WIC Program can provide a professional interpreter (language or sign language) for my WIC appointment at no cost to me. That person is a skilled interpreter trained to protect my privacy. That person understands my language and words related to the WIC Program.

I understand there are risks if I choose not to use a professional interpreter. If I choose to have a friend or family member as my interpreter, it is possible they may:

Not know the correct words and give me wrong information
Add or leave out information
Learn things about me or my child that I may not want to share
Tell others about me or my child's health condition or life situation
Misunderstand what WIC staff says

I choose not to use the free interpreter services provided by the WIC Program and will use my own interpreter. My interpreter is at least 18 years of age.

Name of interpreter*

Relationship to me*

I will not hold the WIC staff or any other personnel at the WIC agency responsible for any adverse results that may occur from my refusal to use a professional interpreter. This form will be valid for one (1) year from the date of signing.

Signature Participant/Parent/Guardian*

Date*

Date

Printed name Participant/Parent/Guardian*

Name

Address

City, State, ZIP

This institution is an equal opportunity provider.

WIC Agency Information