WIC Peer Shopper Consent:

Your family has been selected to participate in the WIC Online Ordering and Delivery Pilot program.
• This short-term pilot program goes into Spring 2022 and includes two shopping trips per month completed by our WIC Peer Shopper.
Current stores in La Crosse County: Festival Foods-Copeland, Woodman’s and Wal-Mart-La Crosse.
• During this pilot program, you will be issued a new eWIC card that will be held by the WIC Peer Shopper. You will only be able to complete online ordering transactions for your WIC benefits.
• Your role will be to place your WIC order online through the designated webcart link (at least 24 hours before requested delivery), communicate with the WIC Peer Shopper as needed and complete a survey upon receiving WIC grocery delivery.
• Please understand you can opt out of the WIC Peer Shopper program at any time without your WIC benefits being affected.

(Electronically completed via IntakeQ, link will be sent by your WIC Project)
__ I agree to have an authorized WIC Peer Shopper do my WIC shopping.

__ I agree that participating in this program will require my current WIC card to be deactivated. A new WIC card will be set up for the authorized WIC Peer shopper to keep and use for my WIC food delivery through Spring of 2022. Ending date subject to change based on WIC Peer Shopper grant funding.

___I agree, once my WIC Peer Shopper has started shopping, I am no longer able to cancel or reschedule my delivery day and/or time.

___I agree, I am responsible for being available and communicating with my WIC Peer Shopper during shopping if any questions or substitutions arise. If I do not reply right away the WIC Peer Shopper will do their best to accommodate.

___I agree that I am responsible for completing the webcart completely with approved substitutions and comments identified on the webcart.

___I agree that if I do not utilize the WIC Peer Shopper program in a timely manner for the month, my WIC benefits may expire by the benefit end date before being used. I understand that some WIC foods may not be available at the time of shopping.

____I agree, if the WIC Program notices you are not utilizing this WIC Peer Shopper Pilot program the WIC agency will reach out to discuss and potentially remove you from the WIC Peer Shopper Pilot Program.

_ I agree, to be home to accept the food on the chosen day, time frame and location that was chosen on the webcart calendar. If I am not home, the WIC Peer Shopper will leave the order at the address provided.

_ I understand the WIC Peer Shopper will notify me via phone and/or text communication, if there is a change in delivery time in case of an emergency.

_ I understand due to weather, road conditions or an emergency the WIC Peer Shopper might need to cancel and reschedule orders.

__ I agree, I will be responsible for submitting/ordering online through the webcart up to two shopping trips per month. * Shoppers are only allowed to purchase WIC foods.

_ I agree, at the time of delivery, I will verify I received all items requested and will complete the survey electronically via the webcart notification.

If I do not want to continue in the WIC Peer Shopper Program, I will let both the WIC Peer Shopper and my local WIC agency know ASAP. A new WIC card will be issued and will take up to 7 business days to be received by mail or an arrangement for pick up from your local WIC clinic.

I understand I can opt out of the WIC Peer Shopper program at any time without my WIC benefits being affected.

I understand that the WIC Program is not responsible for the food items once they have been delivered. Refrigerate cold foods promptly upon delivery.
I, ______________________________, understand and agree to enroll in this optional WIC Peer Shopper program through the __ WIC Program.
I hereby acknowledge that I have read and understand the above procedures.