WIC Document Submission
Hidden
Status
(Required)
Pending
Completed
Let’s get some basic information:
Name
(Required)
First name
Last name
Email address (optional)
Phone number
(Required)
What’s your WIC status?
WIC Card Number (optional)
Do you have medical assistance (state insurance), SNAP, or cash assistance?
(Required)
Yes
No
What is your Access Card/PA State ID Number?
Where is your WIC center located?
(Required)
Please select
Berks County
Bradford County
Bucks County
Carbon County
Lackawanna County
Lehigh County
Luzerne County
Monroe County
Montgomery County
Northampton County
Pike County
Schuylkill County
Sullivan County
Susquehanna County
Tioga County
Wayne County
Wyoming County
Choose the center that best suits your needs:
Quakertown WIC Center –
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Warminster WIC Center –
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Bristol WIC Center –
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Choose the center that best suits your needs:
Berks WIC Nutrition Center – –
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Kutztown WIC Satellite Center –
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Choose the center that best suits your needs:
Towanda WIC Center –
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Choose the center that best suits your needs:
Carbon County WIC Center –
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Choose the center that best suits your needs:
Scranton WIC Center –
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MFHS Circle of Care Scranton –
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Childs WIC Center –
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Choose the center that best suits your needs:
Lehigh Valley WIC Center –
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Casa Guadalupe WIC –
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Choose the center that best suits your needs:
Hazleton WIC Center –
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Wilkes-Barre WIC Center –
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Choose the center that best suits your needs:
Tobyhanna WIC Center –
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East Stroudsburg WIC Center –
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Choose the center that best suits your needs:
Pottstown WIC Center –
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Colmar WIC Center –
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Norristown WIC Center –
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Choose the center that best suits your needs:
Hispanic Center of Lehigh Valley WIC –
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Easton WIC Center –
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Choose the center that best suits your needs:
Hamlin WIC Center –
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Choose the center that best suits your needs:
Sullivan Co Medical Ctr. (Temporarily Closed) –
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Choose the center that best suits your needs:
NEPA Community Health Care WIC –
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Choose the center that best suits your needs:
Shenandoah WIC Center –
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MFHS Pottsville Center –
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Tamaqua WIC Center –
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Choose the center that best suits your needs:
Wellsboro WIC Center –
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Choose the center that best suits your needs:
Hamlin WIC Center –
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Choose the center that best suits your needs:
Tunkhannock WIC Center –
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Who is receiving benefits?
(Required)
Yourself
Child/Children
Both
What’s your address?
Address
(Required)
Street Address
Street Address 2
City
State
Please select
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Postal code
Please upload your document:
Browse files
(Required)
Drop files here or
Select files
Accepted file types: jpg, jpeg, png, pdf, doc, txt, docx, xls, xlsx, csv, Max. file size: 64 MB.
Why are you filling out this form today? (optional)
I am new to WIC (
click here
for the documents needed for your first visit)
I am coming back to WIC (
click here
for the documents needed for your visit)
I am submitting a proof of pregnancy document
I am submitting a formula prescription
I am submitting height and weight documents
I am submitting blood work documents
Something else (referral or other documents)
Please review your information and tap submit to send your information to a WIC Representative.
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