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Please take a few minutes to provide the following information. After you submit this form, someone from your local WIC office will contact you. Completing this form does not guarantee your enrollment in the program. Pennsylvania WIC is funded by the United States Department of Agriculture. This institution is an equal opportunity provider.

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What language do you prefer?*
- English
- Español
Complete la solicitud en español aquí: Solicitud de WIC en español

Do you live in Pennsylvania?*
- Yes
- No
Oops, this application is only for people who live in Pennsylvania. Contact the WIC program in your state to learn more.
In which county do you live?*

Have you been on WIC before?*
- Yes
- No
WIC is a nutrition program for women, infants and children younger than 5. Please select all statements that are true of you.*
- I have an infant younger than 1.
- I have a child between 1 and 5 years old.
- I am pregnant.
- I am a foster parent or legal guardian of a child younger than 5.
- I experienced a pregnancy loss within the past 6 months.

Name*
First Last
Address
Street Address Address Line 2 City State ZIP Code
Email*
Phone*

What’s the best way to contact you?*
- Phone
- Text
- Email
Do you prefer a morning or afternoon appointment?*
- Morning
- Afternoon
How did you hear about us?*
- County Assistance Office
- Facebook
- Food Bank
- Friends/Family
- Head Start/Early Head Start
- Health Fair/Outreach Event
- OBGYN/Doctor
- Postures/Brochures
- Search Engine
Comments
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1-877-743-1372

Paid for by PA taxpayer dollars. Pennsylvania WIC is funded by the United States Department of Agriculture. This institution is an equal opportunity provider.

Non-discrimination Statement | Español | Staff Program Forms

1-833-834-2900

Pennsylvania WIC is funded by the United States Department of Agriculture. This institution is an equal opportunity provider.

Non-discrimination Statement | Español

| Staff Program Forms

1-877-743-1372