WIC Staff and Clinic Change Form

Use this form to:

  • Add and remove clinic staff
  • Change clinic staff role, email, and supervisor
  • Update fiscal contact and contract information
  • Update clinic information

This form updates the Learning Center, the DOH WIC Local Agency Directory, and email distribution lists only. Please continue to make changes and updates for your clinic within Cascades. If you have questions about this form please contact WAWICTraining@doh.wa.gov or WICAddress@doh.wa.gov.

Information collected via this form may be subject to release in accordance with RCW 42.56 (Public Records Act).

Person completing form:

I want to (select all that apply):

Add Clinic Staff

ADD staff that have never had a Learning Center (LC) account.

  • If you're hiring a staff member from another WA agency and they already have a LC account, select Change clinic staff role, email, and supervisor to update to update the user's account. Please don't add a new account for an existing staff member.

Note: You can use the plus and minus icons on the right to add multiple entries.

Add Staff

Remove clinic staff

Remove staff members that no longer work in WIC and remove their WICHealth account and Zoom license (if applicable).

Note: You can use the plus and minus icons on the right to add multiple entries.

Remove Staff

Make clinic staff changes

Make changes in staff information ie: role, name, email address, supervisor, etc. Indicate the staff member whose information you are changing.

Note: You can use the plus and minus icons on the right to add multiple entries.

Please complete the fields and select all checkboxes that apply.
Changes Staff

Update contract and fiscal contact information

Add, remove, or update agency contract and fiscal contact information.


I want to (select all that apply):

Add Fiscal/Contract Contact

Please complete the fields and select all checkboxes that apply. Indicate if person is a contract signer, and types of correspondence to receive.

Add Fiscal/Contract Contact

Remove Fiscal/Contract Contact

Remove Fiscal/Contract Contact

Update Fiscal/Contract Contact

Update Contact Fiscal/Contract Information

Make clinic changes

Make changes in clinic information, ie: hours, phone number, fax number, location.

Note: You can use the plus and minus icons on the right to add multiple entries.

Changes Clinic
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