HIPPY Eligibility Questionnaire
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
Clear selection
My child was below 5 lbs. 9 oz. when born
Clear selection
Child is in custody of or living with a family member other than the parent (parent is not in household)
Clear selection
Child has a parent activated for overseas military duty
Clear selection
One parent was under 18 years of age at birth of child
Clear selection
Child is in foster care
Clear selection
Child has an immediate family member (mother, father, sibling) arrested or convicted of a drug related offense
Clear selection
A family member has (at any time) been in a treatment center for substance abuse and/or addiction
Clear selection
Child already has an IEP and receiving services from the cooperative or another facility
Clear selection
A family member or child has been a victim of abuse or neglect
Clear selection
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