HIPPY Eligibility Questionnaire

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Please fill out the following and check any that may apply to you or your family. This will help us to see how your family will be able to qualify for our program. Thank you!

Email *

Parent Name *

Child Name *

One or both parents do not a high school diploma or GED

Yes

Clear selection

My child was below 5 lbs. 9 oz. when born

Yes

Clear selection

Child is in custody of or living with a family member other than the parent (parent is not in household)

Yes

Clear selection

Child has a parent activated for overseas military duty

Yes

Clear selection

One parent was under 18 years of age at birth of child

Yes

Clear selection

Child is in foster care

Yes

Clear selection

Child has an immediate family member (mother, father, sibling) arrested or convicted of a drug related offense

Yes

Clear selection

A family member has (at any time) been in a treatment center for substance abuse and/or addiction

Yes

Clear selection

Child already has an IEP and receiving services from the cooperative or another facility

Yes

Clear selection

A family member or child has been a victim of abuse or neglect

Yes

Clear selection

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Wilbur D. Mills Education Service Cooperative.

Does this form look suspicious? Report

Forms