PARTICIPANT INFORMATION
Thank you for your interest in LoveU2Pieces. 

At this time we are going through a program evaluation process and expect to resume programming in June. 

After submitting the form below, we'll reach out to you this spring with further details. Your involvement and support in our programs are highly valued, and we look forward to connecting with you and learning more about your child.

If you have any questions or immediate concerns please reach out to Executive Director Leigh Rolnicki at leigh@loveu2pieces.org.

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Please select the program that you are registering for: *
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Early Childhood (pre-K/Kindergarten)
Social Connections (Grades 1-5)
Teen Time
If you are registering for Early Childhood, please select the program timeframes that would work best for you:
Have you already set up a consultation? If so, what date and time?
If you haven't set up a consultation, we will contact you to schedule.
Participant First Name
Participant Middle Name
Participant Last Name
Gender
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Birthday
MM
/
DD
/
YYYY
Grade
School Name and District or Homeschooled?
Medical Diagnosis
Educational Classification
Does your child have an IEP?
If so, please feel free to submit a copy so that we may best understand your child.
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Participant Street Address
Participant City
Participant State
Participant Zip Code
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