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!
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
Same name and birth date as above
Mother's First Name
Mother's Last Name
Mother's Birth Date
Expected Delivery Date
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.
To add a child to the list below, enter the following information and click or press "ADD CHILD"
Birth Date
click toADD CHILD
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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