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OurSpaceLA 23-24 Adult 23+ Enrollment Form
Please verify reCaptcha before submitting the form.
Make OurSpace... Your Space
2023-2024 Enrollment Form
ADULTS Ages 23+
www.vbs.org/ourspacela
Notice: Enrollment is due August 31, 2023
Please Check The Programs That You Will Attend
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
Address
City, State, Zip
Participant lives with:
Please Select One
Both Parents
Mother
Father
Guardian
On My Own
Other
Group Home, IL Program
Other:
What is the name:
Supervisor Name:
Contact information for Sundays:
Who is responsible for tuition:
Please Select One
Both Parents
Mother
Father
Guardian
Participant
Other
Other:
Will your residence arrangements affect attendance?
Please Select One
Yes
No
If yes, please explain
How will you arrive and leave the OurSpace programs that you attend (method/s of transportation):
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?
Please Select One
Yes
No
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?
Please Select One
Yes
No
If yes, which one:
JEWISH EDUCATION
Have you previously received a Jewish education?
Please Select One
Yes
No
Provide the name of school or instructor:
Do you attend or belong to a synagogue or any other Jewish organization or program?
Please Select One
Yes
No
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?
Yes
No
Please comment:
Are you happier alone or with other people?
Alone
With other people
Please comment:
Do you get along with people of the same sex?
Yes
No
Please comment:
Do you get along with people of the opposite sex?
Yes
No
Please comment:
Is it easy for you to follow instructions?
Yes
No
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?
Yes
No
Please comment:
Do you need a kinesthetic approach to help engage in learning?
Yes
No
Please comment:
Do you have fine motor/gross motor challenges?
Yes
No
If yes, please explain:
Do you have any fears and/or are there any situations that cause you anxiety?
Yes
No
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?
Yes
No
If yes, please describe:
Do you exhibit aggressive behavior towards yourself or others?
Yes
No
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?
Please select one
Yes
No
Do you 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?
Do you have past or present health concerns of which we should be aware?
Please Select One
Yes
No
If yes, please explain:
Do you have allergies?
Please Select One
Yes
No
If yes, please explain the allergies and possible reactions:
Do you have any food restrictions or a special diet?
Please Select One
Yes
No
If yes, please explain:
Are you 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:
Are you receiving psychological therapy?
Please Select One
Yes
No
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.
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 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 permission
I 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
Yes, I/We have read the Valley Beth Shalom:
Our Brit- A Covenant of Shared Responsibility
.
*
PLEASE TYPE NAME BELOW TO AGREE
*
PLEASE TYPE NAME BELOW TO AGREE
TUITION AND SCHEDULES
Participant's First and Last Name:
First and Last Name Person Responsible for Tuition:
Please select the program(s) your are requesting enrollment for:
The Artistic Spectrum (19-Adult) - $1,180
B’Yachad Bet (Ages 14-Adult) - Membership & Programs - $180
Kolot 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 31, 2023 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 Orit Rappaport at
orappaport@vbs.org
.
Sat, July 27 2024 21 Tammuz 5784