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!

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Contact Information:

First Name:

Last Name:

Street Address:

City:

Zip Code:

County:

E-mail Address:

Phone Number:

Date of Birth:

Appointment Preference:

Morning Afternoon

Application Status:



Who is applying for benefits?

Mother
Child(ren)

Mother's Information:

Same name and birth date as above

Mother's First Name:

Mother's Last Name:

Mother's Birth Date:

Mother is Currently:



Expected Delivery Date:

Mother's Race:

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White

Mother's Ethnicity:

Hispanic or Latina
Not Hispanic or Latina

The collection of race & ethnicity information is strictly for statistical reporting requirements and has no effect on the determination of eligibility to participate in the WIC program.

Medical Assistance:

Yes No

Child Information:

To add a child to the list below, enter the following information and click or press "ADD CHILD"

First Name:

Last Name:

Birth Date:

Child's Race:

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White

Child's Ethnicity:

Hispanic or Latino
Not Hispanic or Latino

The collection of race & ethnicity information is strictly for statistical reporting requirements and has no effect on the determination of eligibility to participate in the WIC program.

Medical Assistance:

Yes No

First Name Last Name Birth Date Race Ethnicity Medical Asst.

You MUST bring the following items to your appointment:

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  • Proof of identity, for example:
    • For a woman – driver’s license, photo ID card, passport or student ID
    • For an infant – birth certificate, crib card or discharge paperwork
    • For a child – birth certificate, crib card or passport
  • Proof of all sources of income for everyone living in the household (ex. pay stubs for the last 30 days, unemployment letter, child support, income tax return for self-employed persons only)
  • ACCESS card (if applicable)
  • Proof of Pennsylvania residency (document with name and current address such as driver’s license, utility bill or recent mail)
  • Immunization record for all children under 2 years old (ex. baby book, health passport), if available
  • Your child(ren) under age 5
  • Proof of pregnancy stating due date (if applicable)
Pregnant woman

I understand that WIC eligibility is determined at the time of my appointment, and completing this pre-application does not guarantee enrollment.