Make OurSpace... Your Space
2021-2022 Enrollment Form
ADULTS Ages 23+

www.vbs.org/ourspacela

Notice: Enrollment is due August 15, 2021

Please Check The Programs That You Will Attend

Artistic Spectrum of Jewish LearningB’Yachad BetKolot Tikvah Choir

PARTICIPANT INFORMATION

Participant First Name

Participant Last Name

Participant Hebrew Name

Date of Birth

Participant Gender

FemaleMale

Participant Email Address

Address

City, State, Zip

Participant lives with:

Other:

What is the name:

Supervisor Name:

Contact information for Sundays:

Who is responsible for tuition:

Other:

Will your residence arrangements affect attendance?

If yes, please explain

How will you arrive and leave the OurSpace programs that you attend (method/s of transportation):

Is your caregiver vaccinated against Covid-19?

PARTICIPANT

First and Last Name

Home Address

City, State, Zip

Home Phone

Cell Phone

Email Address

Student/Profession

School or Business Address

School or Business City, State, Zip

Business Phone

Are you a member of a Synagogue?

If yes, which one:

EMERGENCY CONTACT

Title

First and Last Name

Relationship to participant

Home Address

City, State, Zip

Home Phone

Cell Phone

Email Address

Profession

Business Address

City, State, Zip

Business Phone

Are you a member of a Synagogue?

If yes, which one:

JEWISH EDUCATION

Have you previously received a Jewish education?

Provide the name of school or instructor:

Do you attend or belong to a synagogue or any other Jewish organization or program?

Which ones:

SOCIAL / BEHAVIOR / LEARNING STYLE

What are your strengths?

What do you love to do (e.g., hobbies, interests, passions)?

Do you make friends easily?

YesNo

Please comment:

Are you happier alone or with other people?

AloneWith other people

Please comment:

Do you get along with people of the same sex?

YesNo

Please comment:

Do you get along with people of the opposite sex?

YesNo

Please comment:

Is it easy for you to follow instructions?

YesNo

Please specify (e.g., a series of instructions, one direction at a time, given directions in writing, etc.)

Do you need verbal and/or visual cues to help you learn and understand something?

YesNo

Please comment:

Do you need a kinesthetic approach to help engage in learning?

YesNo

Please comment:

Do you have fine motor/gross motor challenges?

YesNo

If yes, please explain:

Do you have any fears and/or are there any situations that cause you anxiety?

YesNo

If yes, please describe:

What behaviors are exhibited as a result of these fears and anxieties?

What makes you angry and how do you exhibit anger?

Do you have any self-stimulating behaviors?

YesNo

If yes, please describe:

Do you exhibit aggressive behavior towards yourself or others?

YesNo

If yes, please explain:

Please comment about specific methods of intervention that are helpful for you. Please be specific so that we can use this information to create the best possible OurSpaceLA experience for you.

Transition, School, Independent Living, or College program you are currently attending:

Program Address:

Program City, State, Zip:

Program Phone:

MEDICAL

Are you vaccinated against Covid-19?

Do you have epilepsy/epileptic seizures?

Are seizures under control?

Date of last seizure:

How are seizures being managed?

Do you have past or present health concerns of which we should be aware?

If yes, please explain:

Do you have allergies?

If yes, please explain the allergies and possible reactions:

Do you have any food restrictions or a special diet?

If yes, please explain:

Are you on a medication program?

Medication:

Specific Schedule:

Dosages:

Prescribing Physician/Psychiatrist 1:

Physician/Psychiatrist 1 Address:

City:

State:

Zip:

Prescribing Physician/Psychiatrist 2:

Physician/Psychiatrist 2 Address:

City:

State:

Zip:

Are you receiving psychological therapy?

How frequently and what is the nature / reason for the therapy?

I give permission to the professional staff of OurSpaceLA programs to speak with the physicians and/or therapists listed below in order to receive and release information regarding my well being.

If yes, your physician/therapist will need a release as well.

Please list the name(s) of the person(s) working with you:

Name of Professional 1:

Professional 1 Phone:

Professional 1 Address:

City:

State:

Zip:

Name of Professional 2:

Professional 2 Phone:

Professional 2 Address:

City:

State:

Zip:

Service Coordinator:

Service Coordinator Phone:

ADULT PARTICIPANT RELEASE

MEDICAL EMERGENCY RELEASE:

In the event of a medical emergency, in accordance with the Valley Beth Shalom emergency procedure, I/we do hereby release the appropriate personnel of VBS to either administer first aid OR release me to an emergency hospital or disaster center, for further treatment, as they deem necessary. Furthermore, I/we authorize appropriate personnel of Valley Beth Shalom, to consent to all emergency medical care for me to be rendered by a duly licensed physician, surgeon, dentist and/or other medical professional. This care may be given under whatever conditions are necessary to preserve my health and safety. I/we further agree to pay all charges for that care and/or treatment. It is understood that if time and circumstances reasonably permit, VBS personnel will try, but are not required to communicate with me prior to such treatment.

* PLEASE TYPE NAME BELOW TO AGREE

Medical Insurance:

ID #:

Prescribing Physician:

Phone:

Address:

City, State, Zip:

Life Sustaining Medication:

Date of Last Tetanus Shot:

IN CASE OF EMERGENCY PLEASE CONTACT:

Emergency Contact 1 Name

Emergency Contact 1 Relationship

Emergency Contact 1 Phone

Emergency Contact 2 Name

Emergency Contact 2 Relationship

Emergency Contact 2 Phone

Emergency Contact 3 Name

Emergency Contact 3 Relationship

Emergency Contact 3 Phone

Out of State Contact Name

Out of State Contact Relationship

Out of State Contact Phone

Should any of the medical, emergency, or release information (including change of address or phone number) change within the duration of the year it is your responsibility to inform the Director of OurSpaceLA in writing.

PHOTO/AUDIO/VIDEO/WEBSITE RELEASE:

I give permission for photographers, slides, video or audio tapes to be taken of me to be used for our calendar, website, public relation purposes and the promotion of OurSpaceLA programs. I understand that none of the above may be used by the mass media for newspaper or television stories without my consent for usage.

* PLEASE TYPE NAME BELOW TO AGREE

DIRECTORY RELEASE:

I give my permission for my name, address, telephone number, and email address to be given to other participants in the OurSpaceLA programs at Valley Beth Shalom.

* PLEASE TYPE NAME BELOW TO AGREE

FIELD TRIP RELEASE:

I give permission and consent to OurSpaceLA and its employees and agents to take my child on field trips as part of the normal curriculum and program and, to the extent possible, absolve OurSpaceLA, Valley Beth Shalom and its employees and agents from any liability for personal injury to my child or property damage, except for injuries resulting from gross negligence of OurSpaceLA, Valley Beth Shalom, or their employees or agents. I understand that for all field trips that require transportation, I will receive a permission slip. Unless I have signed the permission slip my child will not be permitted to go on the trip.
I do not give permission and consent to OurSpaceLa and its employees and agents to take my child on field trips.

* Do you give permission?

I give permissionI do not give permission

* PLEASE TYPE NAME BELOW TO AGREE

ARTISTIC SPECTRUM OF JEWISH LEARNING ADULT PROGRAM

INDEPENDENT LIVING SKILLS RELEASE:

I will independently travel to and/or from Valley Beth Shalom. I will drive myself, carpool with others, or use private companies such as Access or public transportation to travel.

PLEASE TYPE NAME BELOW TO AGREE

Please indicate what form of transportation you will be using from above:

I understand that I need to sign in when I arrive to an OurSpaceLA program and to sign out at the guards gate before leaving the facility.

PLEASE TYPE NAME BELOW TO AGREE

Please be advised: Upon returning to campus, all participants, parents, caregivers and support staff who are on site are expected to follow all VBS COVID-19 related protocols.

Yes, I/We have read the Valley Beth Shalom: Our Brit- A Covenant of Shared Responsibility.

* PLEASE TYPE NAME BELOW TO AGREE

Yes, I/We understand that everyone who chooses to attend the in person sessions will be expected to follow all VBS, CDC, LA COUNTY Dept. Of Public Health COVID-19 related protocols.

* PLEASE TYPE NAME BELOW TO AGREE

PLEASE NOTE: Most supplies and materials will be prepared and individually labeled for participants and they will be stored at VBS for use from week to week. Participants who continue to join us virtually will continue to receive the necessary items to be used at home via pick up or delivery.

TUITION AND SCHEDULES

Participant's First and Last Name:

First and Last Name Person Responsible for Tuition:

Our plans are to return to in person sessions for all programs during the 2021-2022 year with some type of a hybrid model offered to those who will need to join virtually.

Please select the program(s) your are requesting enrollment for:

The Artistic Spectrum (19-Adult) - $1,150B’Yachad Bet (Ages 14-Adult) - Membership & Programs - $136Kolot Tikva Voices of Hope Choir (All Ages) - $180
The Artistic Spectrum: Price includes all supplies needed and for those joining virtually will be available for pick up once a month
Meets on Sundays from 9:15-11:30AM
Program includes guest artists and specialists

B'Yachad Bet: Monthly social activities on and off site

Kolot Tikva Voices of Hope Choir: Participation may include in person and/or virtual performances and presentations

Due to the current crisis we are asking families who are able to help, to consider sponsoring another OSLA participant for any program and at any amount.

Notice: After selecting Submit below, your enrollment will be pending and our office will contact you to arrange a payment plan and finalize your registration.

It is important that your completed enrollment form is received by August 15, 2021 so that we can plan our programs.

If you have a question or concern regarding your payment or payment plan, please contact Susan at sngilboa@vbs.org or Allison Truscheit atruscheit@vbs.org.

OurSpaceLA 2021/2022 Adult 23+ Enrollment Form

Make OurSpace... Your Space
2021-2022 Enrollment Form
ADULTS Ages 23+

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OurSpaceLA 2021/2022 Adult 23+ Enrollment Form

Make OurSpace... Your Space 2021-2022 Enrollment Form ADULTS Ages 23+

Quick Links

This Week

Today's Calendar

Candle Lighting

Havdalah

Follow Us

Make OurSpace... Your Space
2021-2022 Enrollment Form
ADULTS Ages 23+