Ensure that you complete all required fields marked with an asterisk (*). Gather the necessary measurements and data before filling out the form. Once completed, submit the form to the requesting agency via email, fax, or physical mail. Refer to the contact information provided by the requesting agency for submission. For online submissions, use the designated online submission form if available.

Ensure timely submission by noting the referral date and the two-week submission deadline.

The Arizona Head Start and WIC Referral Form is designed to facilitate the exchange of client information between Arizona Head Start Programs and the WIC Program. Accurate completion of this form ensures that all relevant client data is shared for effective coordination and service delivery. By filling out and submitting this form, families can access the necessary services and support from both programs efficiently.

• 1. Participation Status: Indicate current participation status in Head Start and WIC programs.
• 2. Date of Referral: Enter the referral date in MM/DD/YYYY format.
• 3. Child's Full Name: Provide the child's full name, including first, middle initial, and last.
• 4. Child's Date of Birth: Enter the child's date of birth in MM/DD/YYYY format.
• 5. Authorized Representatives'/Caregivers' Full Name: Provide the full name of the authorized representative or caregiver.
• 6. Family's Contact Phone Number: Enter the family's primary contact phone number.
• 7. Height: Record the child's height and the date it was taken.
• 8. Weight: Record the child's weight and the date it was taken.
• 9. Hgb: Record the child's hemoglobin value and the date it was taken.
• 10. Referring WIC/Head Start Clinic Contact Information: Provide the contact information of the WIC/Head Start clinic making the referral.
• 11. Name of Staff Member Completing the Referral: Enter the full name of the staff member completing the referral.
• 12. Optional: To Be Completed By Participants: Section to verify permission to be contacted by the programs for further outreach and enrollment.
• 13. Would you like to be contacted: Indicate if you would like to be contacted by WIC or Head Start to learn more about the program.
• 14. Authorized Representatives'/Caregivers' Signature: Obtain the signature of the authorized representative or caregiver.

Failure to submit the Arizona Head Start and WIC Referral Form may result in delays or inability to access program services. It's crucial to complete and submit the form within the specified timeframe to ensure timely service delivery.

• Service Delays: Delays in accessing WIC and Head Start program services.
• Incomplete Referrals: Incomplete information may hinder the referral process.
• Missed Opportunities: Missing the submission deadline might cause missed opportunities for program benefits.

• 1. Client Referrals: When referring clients from WIC to Head Start or vice versa.
• 2. Program Enrollment: To provide necessary information for program enrollment and participation.
• 3. Service Coordination: To coordinate services between Head Start and WIC for shared clients.
• 4. Measurement Documentation: To document and share recent measurements and health data.
• 5. Authorization Verification: To verify authorization for contact and outreach for further enrollment.