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OurSpaceLA 24-25 Child & Teen Enrollment 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. 

Notice: Enrollment is due September 18, 2024
 

PARTICIPANT INFORMATION
PARENT/LEGAL GUARDIAN 1

PARENT/LEGAL GUARDIAN 2
JEWISH EDUCATION
SOCIAL / BEHAVIOR / LEARNING STYLE
If yes, please forward copies to earzio@vbs.org.
MEDICAL
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.
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.

 

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):

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.
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.
Yes, I/We have read the Valley Beth Shalom: Our Brit- A Covenant of Shared Responsibility.  
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.
Sat, September 14 2024 11 Elul 5784