HIPPY Interest & Eligibility form

HIPPY - Interest and Eligibility Form

Thank you for your interest in the HIPPY Pasadena program!

Thank you for your interest in the HIPPY Pasadena program!
Please fill out the information below to determine if you qualify for HIPPY Pasadena.

Your child must turn 2 years of age by October 31 and you, and your family must reside within the Pasadena, Altadena, or Sierra Madre area to qualify for the program.

If you are unsure whether you qualify, fill out the form and a Parent Specialist will contact you with additional information.
Once you complete the information below, a Parent Specialist will contact you between 2-3 business days. Completion of this form does not mean you are enrolled in the program. Parent Specialists work directly with parents/caregivers and not with children. Parents are their child's first teachers.

Your name
Your name
First
Last
Your child's name
Your child's name
First
Last
Parent primary language
Preferred Method of Contact
Preferred time for meetings
Is your child currently enrolled in a preschool program? (Enrollment in HIPPY Pasadena does not affect standing in preschool or other programs.)
Parent/Guardian's Highest Level of Education
Please check if you are eligible/currently enrolled in one or more of the following programs (select all that apply):
How would you describe the condition of your child's teeth?
During the past 12 months, has your child had frequent or chronic difficulty with any of the following? (check all those which apply)
During the past 12 months, did your child see a dentist or other oral health care provider for any kind of dental or oral health care?
If yes, check all those which apply
After you hit SUBMIT button below, your interest form will be submitted and you will receive a confirmation of your submission.
Please, avoid submitting duplicate requests.