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OurSpaceLA 24-25 Child & Teen Enrollment Form
Please verify reCaptcha before submitting the form.
Make OurSpace... Your Space
2024-2025 OSLA SHAARE TIKVA WEEKLY CLASSES AND B’YACHAD ALEF (a language and social development group) for Children ages 3-18.
www.vbs.org/ourspacela
Notice: Enrollment is due September 18, 2024
Please Check The Programs That You Will Attend
OurSpaceLA - Shaare Tikva – “Gates of Hope” (Ages 3 – 18), - $995.00 - Weekly on Sundays (9:15-11:30 AM) Shaare Tikva (Gates of Hope), is a weekly Hebrew School program for neurodivergent students with unique abilities.
OurSpaceLA - B’Yachad (Together) Alef (ages 4-14), - $360 - Monthly on Sundays (11:30 A.M. -1:00 P.M.) B’Yachad Alef (Together), is a monthly social language therapy program for children aged 4 to 14, designed to enhance social communication skills
OurSpaceLA - Both Shaare Tikva and B'Yachad Alef - $1,199.00
PARTICIPANT INFORMATION
Participant First Name
Participant Last Name
Participant Hebrew Name
Date of Birth
Participant Gender
Female
Male
Non Binary
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:
Siblings/Other Household Members (e.g., Step-parents, grandparents living with child) Please provide Name(s)/Relationship(s):
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 earzio@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)
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
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
Yes, I/We have read the Valley Beth Shalom:
Our Brit- A Covenant of Shared Responsibility
.
*
PLEASE TYPE NAME BELOW TO AGREE
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 September 18, 2024 so that we can plan our programs.
If you have a question or concern regarding your payment or payment plan, please contact Emily at earzio@vbs.org.
Sun, December 22 2024 21 Kislev 5785
