HIPPY Registration Form

HIPPY Registration Form

HIPPY = Home Intervention Program for Parents of Pre-School age Youngsters. Parents register themselves to participate in the program to get support and learn skills to become their child's first teacher. HIPPY is an evidence-based program that increases a child's school readiness. We look forward to having you join the HIPPY family!
Child Information

We are currently enrolling children ages 2-4 that live in Indiantown, Port Salerno, Golden Gate, East Stuart, or Hobe Sound.
Child Name*

First NameLast Name
Child Date of Birth

MonthDayYear
Date
FemaleMale
EnglishSpanishOther
NoYes, 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, etc. The primary point of contact for the child should be listed here.
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
EnglishSpanishHaitian CreoleOther
How did you hear about us?*
If an individual referred you, please share their name below. If a community partner is completing this for a client, please include your contact information below.

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

I will meet with my assigned HIPPY Home Visitor in my home weekly at a regularly scheduled and convenient time (9:00am - 5:00pm).I will provide a clear, quiet workspace for my home visits. If my children will be home, I will plan activities to limit interruptions while I work with the Home Visitor.I will attend monthly HIPPY group meetingsI understand the HIPPY Home Visitor is meeting with me, as the Parent/Caregiver, to review HIPPY packets and activities. I am responsible for completing the packet with my child each week, which includes 5 different 5-15 minute activities.
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