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HPNC Learning Hub - IAC Recipient Survey
Please complete this form if you are interested in using IAC funding to pay for your child to enroll in HPNC's 2020 student Learning Hub
* Indicates required question
Email
*
Your email
Your phone number
*
Your answer
Your Name (Parent applying / approved for IAC)
Your answer
First Child's Name
Your answer
First Child's Date of Birth
MM
/
DD
/
YYYY
Second Child's Name (leave blank if not applicable)
Your answer
Second Child's Date of Birth
MM
/
DD
/
YYYY
Are you already approved for Illinois Action for Children?
Yes
No
In process of applying
Clear selection
If yes, is HPNC your designated provider?
yes
No
In process of changing providers
Clear selection
Have your children attended HPNC with IAC funds in the past?
Yes
No
Clear selection
If yes to above, what is your IAC expiration date?
MM
/
DD
/
YYYY
Is there anything more that you want us to know about your IAC eligibility status? If so please write here. Once complete, please email our Program Director, Dr. Johari Shuck:
jshuck@hpnclub.org
to let her know that your survey is complete. Thank you!
Your answer
A copy of your responses will be emailed to the address you provided.
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