WIC Pre-Application Portal

Apply today!

We have resources, knowledge and tools to help you be the parent you want to be. If you’re pregnant or a caregiver of a child under five years old, you can get the right personalized support for you and your family.

All caregivers are welcome. Moms, dads, grandparents caring for grandchildren and foster parents can all apply for WIC!

Before you begin, you may want to check your eligibility for WIC here. Am I eligible for WIC?

Signing up is easy! Start online by completing this form. If you need help, we are here for you at 1-800-360-6150.

After you submit this pre-application form, one of our friendly WIC staff will contact you to set up an appointment.

Note that completing the form does not guarantee your eligibility or enrollment in the program. Eligibility will be determined during your first WIC appointment.

Guardian/Caregiver First Name:

Caregiver First Name is required.

Guardian/Caregiver Last Name:

Caregiver Last Name is required.

Guardian/Caregiver Birth Date:

Caregiver Birth Date is required. Caregiver Birth Date is invalid.

The information obtained from this pre-application will remain confidential according to WIC regulations.

The next part of this pre-application will collect information about members of your household that may be eligible for WIC. There is one question on each of the next 5 pages.

If you or someone in your household match the specific criteria listed, please check the box, fill out the name and DOB, and click “Add.” (Note: Multiple names can be added on each page by filling out another name and DOB and clicking “Add” again.) Then click “Next” to go on to the next question.

If no household members match the specific criteria, simply click “Next” to go on to the next question.

An infant less than 1 year old.

First Name: First Name is Required

Last Name: Last Name is Required

Birth Date: Birth Date is Required Birth Date is Invalid Age must be less than 1 year Age must be between 1 and 5 years old Age must be between less than 5 years old

Male Female Gender is Required

Please click Add or blank out fields.

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A child between 1 and 5 years old.

First Name: First Name is Required

Last Name: Last Name is Required

Birth Date: Birth Date is Required Birth Date is Invalid Age must be less than 1 year Age must be between 1 and 5 years old Age must be between less than 5 years old

Male Female Gender is Required

Please click Add or blank out fields.

e1d276c6-fccf-4ef1-aeda-67701063c2d2 2

A foster child less than 5 years old.

First Name: First Name is Required

Last Name: Last Name is Required

Birth Date: Birth Date is Required Birth Date is Invalid Age must be less than 1 year Age must be between 1 and 5 years old Age must be between less than 5 years old

Male Female Gender is Required

Please click Add or blank out fields.

2898da19-bcfb-432c-830d-b4a8874e5bb2 3

A pregnant woman.

Check if the same as the Caregiver.

First Name: First Name is Required

Last Name: Last Name is Required

Birth Date: Birth Date is Required Birth Date is Invalid Age must be less than 1 year Age must be between 1 and 5 years old Age must be between less than 5 years old

Male Female Gender is Required

Please click Add or blank out fields.

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A woman whose pregnancy ended in the last 6 months.

Check if the same as the Caregiver.

First Name: First Name is Required

Last Name: Last Name is Required

Birth Date: Birth Date is Required Birth Date is Invalid Age must be less than 1 year Age must be between 1 and 5 years old Age must be between less than 5 years old

Male Female Gender is Required

Please click Add or blank out fields.

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We’re sorry. You may not be eligible for the WIC program, but here are some other resources that might be helpful.

What is the Primary Language spoken in your household?

Do you need an Interpreter?

Yes No

Interpreter needed is required.

Do you or your child have any Special Needs?

What is the best number to reach you?

Phone Number is required.

What is the best time to call you?

Email Address

Email Address is required. Email Address is invalid.

Mailing Address Line 1

Mailing Address Line 2

City:

City is required.

State:

ZIP

Please select a Zip Code.

County:

Are you currently Homeless?

Yes No

Answer is required.

Have you been on WIC before?

Yes No

Answer is required.

Are you or a member of your household currently receiving AHCCCS, SNAP, TANF, or Commodities (FDPIR)?

Yes No

Answer is required.

Clinic Selected for appointment

Please select a Clinic. A clinic was unable to be assigned please call your local WIC agency.

What is your preferred day for an appointment?

What is your preferred time for an appointment?

Is there any additional information you would like to share with WIC?

WIC eligibility will be determined at the time of my appointment, and completing this pre-application does not guarantee enrollment. This institution is an equal opportunity provider. Please read the Full Non-Discrimination Statement

I accept the terms of this pre-application.

Please check the Captcha checkbox.