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OurSpaceLA 23-24 Child, Teen & Young Adult Enrollment Form Ages 3-22

Make OurSpace... Your Space
2023-2024 Child, Teen & Young Adult Enrollment Form
Ages 3-22

Notice: Enrollment is due August 31, 2023





If yes, please forward copies to

If yes, your physician/therapist will need a release as well.
Please list the name(s) of the person(s) working with your child:
If yes, please include the name and contact information.


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.



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):

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.

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.

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.
  • 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.

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.  
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 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.  


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
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  or Orit Rappaport at
Sun, April 14 2024 6 Nisan 5784