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OurSpaceLA 23-24 Adult 23+ Enrollment Form

 


Make OurSpace... Your Space
2023-2024 Enrollment Form
ADULTS Ages 23+



Notice: Enrollment is due August 31, 2023
 

PARTICIPANT INFORMATION
PARTICIPANT

EMERGENCY CONTACT
JEWISH EDUCATION
SOCIAL / BEHAVIOR / LEARNING STYLE
MEDICAL
If yes, your physician/therapist will need a release as well.
Please list the name(s) of the person(s) working with you:
 
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. 

 

IN CASE OF EMERGENCY PLEASE CONTACT:

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

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
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.
Mon, April 29 2024 21 Nisan 5784