OurSpaceLA 24-25 Child & Teen Enrollment Form - Form (2024)

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 First Name

Participant Last Name

Participant Hebrew Name

Date of Birth

Participant Gender

FemaleMaleNon Binary

Participant Email Address

Secular School-Grade

Address

City, State, Zip

Child lives with:

Other:

Parents are:

Parent responsible for tuition:

Other:

Siblings/Other Household Members (e.g., Step-parents, grandparents living with child) Please provide Name(s)/Relationship(s):

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?

If yes, which one:

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?

If yes, which one:

Has your child previously attended a Jewish school or received private Jewish instruction?

Provide the name of school or instructor:

Does your child attend or belong to any Jewish youth programs?

Which ones:

What are your child's strengths?

What does your child love to do (e.g., hobbies, interests, passions)?

Does your child make friends easily?

YesNo

Please comment:

Is your child happier alone or with other children?

AloneWith other children

Please comment:

Does your child get along with people of the same sex?

YesNo

Please comment:

Does your child get along with people of the opposite sex?

YesNo

Please comment:

Does your child follow instructions?

YesNo

Please specify (e.g., a series of instructions)

Does your child need verbal and/or visual cues to learn?

YesNo

Please comment:

Does your child need a kinesthetic approach to help engage him/her in learning?

YesNo

Please comment:

Does your child have fine motor/gross motor difficulties?

YesNo

If yes, please explain:

Does your child have any fears and/or are there any situations that cause him/her anxiety?

YesNo

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?

YesNo

If yes, please describe:

Has your child exhibited aggressive behavior towards himself/herself or others?

YesNo

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?

YesNoIf yes, please forward copies to earzio@vbs.org.

If no, please explain:

Has your child been professionally evaluated?

YesNo

If yes, what were the results and/or diagnoses (Please indicate below)

Does your child have epilepsy/epileptic seizures?

Are seizures under control?

Date of last seizure:

How are seizures being managed?

Are there any past/present health concerns of which we should be aware?

If yes, please explain:

Does your child have allergies?

If yes, please explain the allergies and possible reactions:

Does your child have any food restrictions or a special diet?

If yes, please explain:

Is your child on a medication program?

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?

How frequently and what is the nature / reason for the therapy?

Is your child receiving behavioral therapy?

Please explain the identified behavior(s) and plan:

Do we need to implement these plans in our classes?

Is your child receiving speech therapy?

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.

If yes, your physician/therapist will need a release as well.

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?

YesNoIf yes, please include the name and contact information.

Service Coordinator:

Service Coordinator Phone:

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 circ*mstances 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 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

* 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 permissionI 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.