WIC Pre-Application

Thank you for your interest in the Women, Infants and Children (WIC) Program! You can get started online by completing this pre-application. Your information is securely sent to the local WIC agency in your county and a WIC staff member will contact you to answer your questions and to schedule an appointment. Please see the income guidelines on this website. Completing this pre-application does not guarantee your enrollment in the program, because your eligibility will be determined at your first WIC appointment. Please submit your pre-application today!

All fields are required.

Participant Information:

First Name:

Last Name:

Street Address:

City:

Zip Code:

County:

E-mail Address:

Phone Number:

Application Status:

Mother's Data:

Expected Delivery Date:

Mother's Birth Date:

Child Data:

Do you have infants or children under the age of 5?
Yes
No

First Name Last Name Birth Date

 Add a Child:

First Name:

Last Name:

Birth Date:

    

I understand that WIC eligibility is determined at the time of my appointment and that I need to bring the following items:

  1. Proof of all sources of income for the entire household, such as:

    • Current pay or unemployment benefits stub
    • Earning statements
    • Income tax return
    • Child support

  2. PA ACCESS card(s)

  3. Proof of Residency, for example:

    • Driver's license
    • Utility bill
    • Rent or mortgage receipts
    • Any document that includes your name and current address

  4. Proof of identity for each person being enrolled or re-certified, for example:

    • Drivers license
    • Birth certificate, hospital record, or crib card
    • Voter registration card
    • Photo ID
    • Passport

  5. Immunization record for children age 2 and under

  6. Proof of pregnancy, including your due date, from your doctor

  7. Blood test results (hematocrit or hemoglobin), if available