Sign In
Forgot Password
or Sign In With
Powered By
ShulCloud
Login
Calendar
LIVE STREAM
DONATE
facebook
instagram
Youtube
About
Upcoming Events/Initiatives
Our Story
Meet our Clergy
Rabbi Nolan Lebovitz
Rabbi Ed Feinstein
Rabbi Nina Bieber Feinstein
Cantor Jacqueline Rafii
Cantor Phil Baron
Cantor Herschel Fox
Rabbi Harold M. Schulweis (z"l)
VBS Newsletter Signup
Contact VBS
LA|Kosher Catering and Events
Bubby's Coffee
VBS Digital Media
The Music of VBS
VBS in the Press
Accessibility
Live Stream @ Home
VBS Annual Report 22-23
Community
VBS Annual Gala 2024
Sayva: A New Approach to Positive Aging
Very Best Shabbat Dinners
Game Day
Adult Community Groups
Sisterhood
Brotherhood
Hazak 60+
VBS Fusion (20's & 30's)
VBS Book Club
VBS Connect
Meditation & Spirituality
VBS Counseling Center
Caring Connection
HOPE Connection, Inc. (Bereavement Groups)
Death and Mourning
Dinner for Docs
So Healthy Together: Mental Health Programs
Spotlight on Doing Good
Community Corner Blog
Learn
Our Schools
VBS Harold M. Schulweis Day School
Early Childhood Center
Etz Chaim Learning Center
OurSpaceLA
Youth Department
Youth Programming
Camp ViBeS: Intentional Experiences
K-6 Programming
Teen Programming
Youth Department Enrollment Form
Support the Youth Department
B'nai Mitzvah Program
Adult Learning
Hazak
Sayva: A New Approach to Positive Aging
EFSHAR presents The Mystical Journey: A Month of Learning
Talking Torah with Rabbi Lebovitz
Weekly Torah Study with Rabbi Feinstein
Thinking Aloud with Rabbi Nolan Lebovitz
Discovery Circle
VBS College of Jewish Studies
Miller Introduction to Judaism (AJU) at VBS
VBS Book Club
Lunch and Learn
The Inner Life of Men
Adult B'nai Mitzvah Program
OurSpace: The Artistic Spectrum of Jewish Learning for Adults
Melton School
Harold M. Schulweis Institute
Music and Dramatic Arts
VBS YouTube Video Archives
VBS Digital Media Projects
"Torah on the Go" Podcast
Thinking Aloud with Rabbi Nolan Lebovitz
Pray
Passover
Names for Prayers in Israel
Yahrzeit Names for this Shabbat
This Shabbat
Efshar Spirituality Center
Daily Minyan
Erev Shabbat (Friday Night)
Weekly Torah Study with Rabbi Feinstein
Rimonim
Shabbat Morning (Saturday)
Main Sanctuary
Tot Shabbat
Library Minyan
Haverim Minyan
N'Shama Minyan
Shabbat Shiur
Meditation @ VBS
B'nai Mitzvah
Death and Mourning
How to Judaism
Jewish Prayer
Jewish Rituals
Jewish Lifecycle Moments
Jewish Holidays
Siddur Sim Shalom
Act
Chesed Connection
VBS Food Bank
Annual Volunteer Events
Volunteer Opportunities with VBS
Knitting Needles/Myra’s Knitting Mavens and Piece by Piece
Volunteer Opportunities in the Greater Community
Helping Children
Helping the Needy
Helping People with Disabilities or Illness
Helping Seniors
Serving our Soldiers
Animal and Environmental Action
Homelessness Task Force
Jewish World Watch
Join
Schedule a Tour of VBS
Renew Your Membership
VBS Premier
New Member Application
Your First Year of Membership
Covenanting Ceremonies
Donate
Annual Campaign
Security Fund
Israel Emergency Fund
Kiddush Sponsorship
Give Online
Legacy Gifts
Calendar
LIVE STREAM
DONATE
facebook
instagram
Youtube
OurSpaceLA 2021/2022 Child, Teen & Young Adult Enrollment Form Ages 3-22
Please verify reCaptcha before submitting the form.
Make OurSpace... Your Space
2021-2022 Child, Teen & Young Adult Enrollment Form
Ages 3-22
www.vbs.org/ourspacela
Notice: Enrollment is due August 15, 2021
Please Check The Programs That You Will Attend
Shaare Tikva
Artistic Spectrum of Jewish Learning
B’Yachad Bet
Kolot Tikvah Choir
PARTICIPANT INFORMATION
Participant First Name
Participant Last Name
Participant Hebrew Name
Date of Birth
Participant Gender
Female
Male
Participant Email Address
Secular School-Grade
Address
City, State, Zip
Child lives with:
Please Select One
Both Parents
Mother
Father
Guardian
Other
Other:
Parents are:
Please Select One
Married
Divorced
Separated
Widowed
Parent responsible for tuition:
Please Select One
Both Parents
Mother
Father
Guardian
Other
Other:
Will participant's residence arrangements affect attendance?
Please Select One
Yes
No
If yes, please explain
Siblings/Other Household Members (e.g., Step-parents, grandparents living with child) Please provide Name(s)/Relationship(s):
Is participant's caregiver(s) vaccinated against Covid-19?
Please Select One
Yes
No
PARENT/LEGAL GUARDIAN 1
Title:
First and Last Name
Relationship to child
Home Address
City, State, Zip
Home Phone
Cell Phone
Email Address
Profession
Business Address
Business City, State, Zip
Business Phone
Are you a member of a Synagogue?
Please Select One
Yes
No
If yes, which one:
PARENT/LEGAL GUARDIAN 2
Title
First and Last Name
Relationship to child
Home Address
City, State, Zip
Home Phone
Cell Phone
Email Address
Profession
Business Address
Business City, State, Zip
Business Phone
Are you a member of a Synagogue?
Please Select One
Yes
No
If yes, which one:
JEWISH EDUCATION
Has your child previously attended a Jewish school or received private Jewish instruction?
Please Select One
Yes
No
Provide the name of school or instructor:
Does your child attend or belong to any Jewish youth programs?
Please Select One
Yes
No
Which ones:
SOCIAL / BEHAVIOR / LEARNING STYLE
What are your child's strengths?
What does your child love to do (e.g., hobbies, interests, passions)?
Does your child make friends easily?
Yes
No
Please comment:
Is your child happier alone or with other children?
Alone
With other children
Please comment:
Does your child get along with people of the same sex?
Yes
No
Please comment:
Does your child get along with people of the opposite sex?
Yes
No
Please comment:
Does your child follow instructions?
Yes
No
Please specify (e.g., a series of instructions)
Does your child need verbal and/or visual cues to learn?
Yes
No
Please comment:
Does your child need a kinesthetic approach to help engage him/her in learning?
Yes
No
Please comment:
Does your child have fine motor/gross motor difficulties?
Yes
No
If yes, please explain:
Does your child have any fears and/or are there any situations that cause him/her anxiety?
Yes
No
If yes, please describe:
What behaviors are exhibited as a result of these fears and anxieties?
What makes your child angry and how does he/she exhibit anger?
Does your child have any self-stimulating behaviors?
Yes
No
If yes, please describe:
Has your child exhibited aggressive behavior towards himself/herself or others?
Yes
No
If yes, please explain:
Please comment about specific methods of intervention that are effective for your child. Please be specific so that we can use this information to create the best possible OurSpaceLA experience for your child.
Secular school now attending:
School Address:
School City, State, Zip:
School Phone:
Describe your child’s program (i.e. special classes, resource room, etc.)
Grade level completed as of this June:
What does your child like best in school?
What does your child like least in school?
How do you feel the OurSpaceLA programs can best contribute to your child’s development and to your whole family?
Are there records or your child's I.E.P., psychological evaluation and/or any other assessments and evaluations?
Yes
No
If yes, please forward copies to
sngilboa@vbs.org
.
If no, please explain:
MEDICAL
Has your child been professionally evaluated?
Yes
No
If yes, what were the results and/or diagnoses (Please indicate below)
Is your child vaccinated against Covid-19?
Please Select One
Yes
No
Does your child have epilepsy/epileptic seizures?
Please Select One
Yes
No
Are seizures under control?
Please Select One
Yes
No
Date of last seizure:
How are seizures being managed?
Are there any past/present health concerns of which we should be aware?
Please Select One
Yes
No
If yes, please explain:
Does your child have allergies?
Please Select One
Yes
No
If yes, please explain the allergies and possible reactions:
Does your child have any food restrictions or a special diet?
Please Select One
Yes
No
If yes, please explain:
Is your child on a medication program?
Please Select One
Yes
No
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:
Is your child receiving psychological therapy?
Please Select One
Yes
No
How frequently and what is the nature / reason for the therapy?
Is your child receiving behavioral therapy?
Please Select One
Yes
No
Please explain the identified behavior(s) and plan:
Do we need to implement these plans in our classes?
Please Select One
Yes
No
Is your child receiving speech therapy?
Please Select One
Yes
No
Please describe the reasons for this therapy and what strategies or tools are being used:
I/We 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 child.
Please Select One
Yes
No
If yes, your physician/therapist will need a release as well.
Please list the name(s) of the person(s) working with your child:
Name of Professional 1:
Professional 1 Phone:
Professional 1 Address:
Professional 1 City, State, Zip:
Name of Professional 2:
Professional 2 Phone:
Professional 2 Address:
Professional 2 City, State, Zip:
Is Regional Center providing services for your child?
Yes
No
If yes, please include the name and contact information.
Service Coordinator:
Service Coordinator Phone:
PARTICIPANT RELEASE
MEDICAL EMERGENCY RELEASE:
In the event of a medical emergency, in accordance with the VBS OurSpaceLA’s emergency procedure, I/we, the undersigned parent(s) or legal guardians do hereby release the appropriate personnel of VBS to either administer first aid OR release the child 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 this child 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 the health and safety of the child. 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/us 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:
PICK UP RELEASE:
In accordance with the OurSpaceLA emergency procedures, you are authorized to release my child to the following (when possible, list below contacts that are located within close proximity to the Valley Beth Shalom):
Pick Up Contact 1 Name
Pick Up Contact 1 Relationship
Pick Up Contact 1 Phone
Pick Up Contact 2 Name
Pick Up Contact 2 Relationship
Pick Up Contact 2 Phone
Pick Up Contact 3 Name
Pick Up Contact 3 Relationship
Pick Up 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 my child 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 parents 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 permission
I do not give permission
*
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 and Grade Level:
Parent's First and Last Name:
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:
Shaare Tikva (Ages 3-18) - $970
The Artistic Spectrum (19-Adult) - $1,150
B’Yachad Bet (Ages 14-Adult) - Membership & Programs - $136
Kolot Tikva Voices of Hope Choir (All Ages) - $180
Shaare Tikva:
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
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
.
Fri, April 19 2024 11 Nisan 5784