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aSuggestion Registration Form

Email of Registered User Or Person Assisting the User

Information About Your IPP Planning / Services & Supports Team

Release of Information and Verification Acknowledgment

To help ensure that all registered users in this Invitation Only platform can participate in a safe, friendly, and predator-free experience, all registrants are verified prior to enrollment.

 

To protect the privacy of the registered users, in accordance with the confidentiality provisions of Title 17, California Code of Regulations, Sections 50500–50550, and Title 22, California Code of Regulations, Section 80070, during the verification process, your information will be handled confidentially and will be used solely for verification purposes.

 

By checking the box and entering your name below, you authorize a designated representative of our organization to contact the person listed above for the limited purpose of confirming the eligibility of the registered user to participate in the aSuggestion platform and for your consent to their participation.

 

No medical, clinical, or personal information will be disclosed to any other party without your explicit written consent, except as otherwise permitted or required by law (e.g., in cases of abuse reporting, health and safety emergencies, or court orders connected with the use of the aSuggestion platform).

I acknowledge and consent to the limited release of contact information for verification purposes as described above.
Yes
Please check one of the following, to indicate why you are authorized to release this information:
I am the Registered User
I am the Parent of the Registered User Who Is Under Age 18
Conservator

Billing Information

Your Credit Card will not be charged until your application is accepted. We will contact you with your approval code and then process payment

Main Address

400 S Covina Blvd

La Puente, CA 91746 USA

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Copyright© 2025

The Roland Center.

 All Rights Reserved.

Call Us

(626) 968-8479

 

Fax

(626) 968-6439

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