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

Address

City

Zip Code

County
Select A County Adams Allegheny Armstrong Beaver Bedford Berks Blair Bradford Bucks Butler Cambria Cameron Carbon Centre Chester Clarion Clearfield Clinton Columbia Crawford Cumberland Dauphin Delaware Elk Erie Fayette Forest Franklin Fulton Greene Huntingdon Indiana Jefferson Juniata Lackawanna Lancaster Lawrence Lebanon Lehigh Luzerne Lycoming McKean Mercer Mifflin Monroe Montgomery Montour Northampton Northumberland Perry Philadelphia Pike Potter Schuylkill Snyder Somerset Sullivan Susquehanna Tioga Union Venango Warren Washington Wayne Westmoreland Wyoming York

E-mail Address

Phone Number

Date of Birth

Appointment Preference

Morning Afternoon

Application Status

New
Re-Applying
Transfer from Another County/State

Who is applying for benefits?

Mother
Child or Children

Mother's Information

Same name and birth date as above

Mother's First Name

Mother's Last Name

Mother's Birth Date

Mother's status

Pregnant
Postpartum (delivered a baby in the last 6 months)
Breastfeeding an infant under 12 months of age

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

Medical Assistance

Yes
No

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.

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	Race	Ethnicity	Medical Asst.

You MUST bring the following items to your appointment:

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

SUBMIT the application RESET the form