HIPPY Registration Form

HIPPY Registration Form

H.I.P.P.Y = Home Instruction Program for Parents of Pre-School Youngsters. HIPPY is an evidence-based program that works one-on-one with a parent/primary caregiver to increases a child's school readiness through daily self-guided learning activities. A HIPPY Home Visitor works with a primary parent/caregiver weekly to role-play HIPPY education packet activities. This form can be completed by a parent or a referring partner. Have questions? Call us (772) 298-8745.
Child Information

We are currently enrolling children ages 2-4 that live in priority communities identified with having the lowest school readiness rate scores in Martin County:
- Indiantown (34956)
- Stuart/Port Salerno/Golden Gate (34997)
- East Stuart (34994)
- Hobe Sound (33455)
If the child you wish to enroll does not live in a listed priority community, Family Empowerment Project encourages you to complete this form to be added to our interest list for families outside our current HIPPY service area.
Child Name

First NameLast Name
Child Date of Birth

MonthDayYear
Date
Child Gender
Child Primary Language

Other
Do you have any concerns about your child meeting developmental milestones?

Yes, please explain
Which elementary school will your child attend?
Parent/Caregiver Information

Any adult caregiver can complete the HIPPY program with a child they are a main caregiver for. This may include, but is not limited to, parents, grandparents, aunts, uncles, adult siblings (18+), etc. The primary parent should be listed in the section below.
Parent Name

First NameLast Name
Parent Date of Birth

MonthDayYear
Date
Primary Address (where Home Visits will happen)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent Phone Number
Format: (000) 000-0000.
Parent E-mail
example@example.com
Parent Primary Language

Other
How did you hear about us?
Are you completing this as a partner referral? If so, please include your name, phone number, and email below so we may contact you if we cannot reach the family you are referring. Thank you for the referral to HIPPY-Martin!

Please select all days of the week and time frames that would allow you to join us for a monthly group meeting.

Rows	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday
Morning (10:00am - 12:00pm)
Afternoon (12:00pm-4:00pm)
Evening (5:00 -7:00 pm)

Read the statements below and check if you agree with each one.
Should be Empty: