WIC Online Pre-Application
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*First Name:	(Required)
*Last Name:	(Required)
*Phone:	(Required)
*E-mail:	(Required)
Address:
City:
State:	Zip:
Application Status: New Re-applying Transfer from Another County/State

Mothers Data:
Pregnancy Postpartum Breastfeeding
*Birth Date:

Infant/Children Data:
Yes No
Name:
Birth Date:
Name:
Birth Date:
Name:
Birth Date:

I understand that I need to bring the following items to my appointment (please read and check each)
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 PA ACCESS card(s) Proof of Residency, for example: Driver's license Utility bill Rent or mortgage receipts Any document that includes your name and current address Proof of identity for each person being enrolled or recertified, for example: Drivers license Birth certificate, hospital record, or crib card Voter Registration card Photo ID Passport Immunization record for children age 2 and under Proof of pregnancy, including your due date, from your doctor Blood test results (hematocrit or hemoglobin) if available
WIC eligibility will be determined at the scheduled WIC appointment

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Last updated March 21, 2011.