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:

Print This List

  • 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)

If possible, complete a dietary questionnaire for each applicant.

  • Woman(pregnant, up to six months postpartum or up to 12 months postpartum if breastfeeding)
  • Infant (under age 1)
  • Child (age 1 to under age 5)
Pregnant woman