Summer@ETTA Participant Application

          ALL information requested is REQUIRED. 

              Contact: Leah Schachter, 818-439-5951 or leah@etta.org

If you would like to start work on the form and save it so you can return and complete it later, first open an account here.

You will then see the yellow "Save Progress" button at the very
bottom of the form.

Please save work frequently!

PARTICIPANT INFORMATION


PARTICIPANT’S PARENT OR GUARDIAN INFORMATION

Father's Information

Is Father's address same as above? *

Mother's Information

Is Mother's address same as above? *

PARTICIPANT FAMILY INFORMATION

Emergency contact (if parents/guardians cannot be reached)

Participant’s current school or day program

MEDICAL HISTORY

EMERGENCY AND MEDICAL INFORMATION

Primary Care Physician

PHOTO & VIDEO RELEASE

There are 2 versions of the release: One for a participant who is competent to sign on his or her own behalf, and another for a minor or one who is not component. Please sign the one relevant to you.

I. Individual

I authorize ETTA, d/b/a Etta Israel Center (“the agency”), to use and disclose my name, image, likeness, photograph and voice for community education, advertising and fundraising purposes, including written and electronic communications and publications.  I understand that the agency is not providing any goods or services in consideration for its use and disclosure of my name, image, likeness, photograph or voice. 

In signing this authorization, I understand that: This information may be redisclosed if the recipient is not required by law to protect the privacy of the information, and in that event the HIPAA privacy regulations would not prevent redisclosure and reuse of the information.  I have a right to refuse to sign this authorization, and my health care, the payment for health care, and health care benefits will not be affected if I do not sign this authorization.  I have a right to see and copy the information described on this authorization form in accordance with agency policies.  I also have a right to receive a copy of this form after I have signed it.  If I sign this authorization, I will have the right to revoke it at any time, except to the extent that the agency has already taken action based upon this authorization. Unless revoked, the authorization will extend until twelve months after you discontinue receiving services at the agency.  To revoke this authorization, please write to ETTA 12722 Riverside Dr. Suite 105 North Hollywood, CA 91607.

Signature (Place your cursor in the box below to create a legal signature) *
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II. Parent 

I, __________________________________, authorize ETTA, d/b/a Etta Israel Center (“the agency”), to use and disclose the name, image, likeness, photograph and voice of my child, ____________________, for community education, advertising and fundraising purposes, including written and electronic communications and publications.  I understand that the agency is not providing any goods or services in consideration for its use and disclosure of my child’s name, image, likeness, photograph or voice. 

In signing this authorization, I understand that: This information may be redisclosed if the recipient is not required by law to protect the privacy of the information, and in that event the HIPAA privacy regulations would not prevent redisclosure and reuse of the information.  I have a right to refuse to sign this authorization, and my health care, the payment for health care, and health care benefits will not be affected if I do not sign this authorization.  I have a right to see and copy the information described on this authorization form in accordance with agency policies.  I also have a right to receive a copy of this form after I have signed it.  If I sign this authorization, I will have the right to revoke it at any time, except to the extent that the agency has already taken action based upon this authorization. Unless revoked, the authorization will extend until twelve months after you discontinue receiving services at the agency.  To revoke this authorization, please write to ETTA 12722 Riverside Dr. Suite 105 North Hollywood, CA 91607.

Signature (Place your cursor in the box below to create a legal signature) *
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SUMMER@ETTA FEE AGREEMENT

Participants who sign up for all 5 weeks are more likely to be accepted into summer@ETTA.
PLEASE SELECT THE DESIRED WEEKS THE PARTICIPANT WILL BE ATTENDING SUMMER@ETTA ($500 week). PLEASE NOTE: PRIORITY IS GIVEN TO THOSE WHO ATTEND ALL 5 WEEKS. *
I understand that payment of $500 per week is my responsibility. If other sources of funding cover a portion of my payment, I agree to be responsible for the remaining amount up to a total of $500 per week per participant. I understand that final amount, schedule of payment, and method of payment will be determined upon receipt of this application.

PAYMENT OF REGISTRATION FEE

Regardless of the number of weeks attending, a $250 registration fee is required to complete this application.

 *
MasterCard
Visa
Visa
Credit card info will be collected on next page (after clicking "continue")
I understand that ETTA will hold a space for my family member based on the information I am submitting on this application upon receipt of my $250 fee.
 
 

APPLICATION FOR FINANCIAL ASSISTANCE

Do you wish to apply for financial assistance? *
Please note that due to budgetary constraints we are unable to guarantee acceptance to summer@ETTA if you are unable to pay in full. We do offer payment plans.
A Note to Our Families: It is our wish that every individual who would like to attend Summer@ETTA be able to do so regardless of ability to pay, however ETTA resources alone are not sufficient to subsidize financial assistance. The Jewish Federation has made some funds available to us and these will be allocated based upon the number of requests we receive. Please complete this application and return it as soon as possible, but not later than March 1. Notifications of financial assistance will be made by May 1st.

FOR SLS CLIENTS ONLY

I understand that SLS is a year round Regional Center funded program and the services that I receive will continue during the month of ETTA’s summer program.  Unless I am ill or out of town, I will not cancel my SLS sessions so that I can attend the summer program.  I also understand that depending on the regular SLS schedule and the number of hours of SLS per week that I receive, some of my services may be provided while I am at the summer program (during Summer@ETTA hours).

Summer@ETTA Intake Survey

Please take a few minutes to complete this survey and return it with your application. If you are a returning family, please answer the questions at the end to document how last year’s Summer@ETTA has impacted your family. Thank you so much!  

Relationship to participant *
 
Question 1: How did you find out about Summer@ETTA? *
 

Question 2: Please rate participant’s independent living skills (such as dental hygiene, grocery shopping, using public transportation) on a scale of 1-10, with 1 being completely dependent on assistance and 10 being completely independent. Circle the number that bests reflects your feelings. *

Question 3: How much do you expect that Summer@ETTA will help to improve participant’s independent living skills? Please check the box that best reflects your feelings: *

Question 4: How important is it to you that Summer@ETTA provide participant with the following (circle a number 1-5, with 1 being the lowest and 5 the highest) *
 12345
Exercise
Sports
Arts and Crafts
Singing
Dancing
Jewish Education
Shabbat Celebrations
---- Independent Living Skills ----
- Dental Hygiene
- Shopping
- Cooking
- Social etiquette
- Self-advocacy
Social Interaction/Conversation
Field Trips
Giving back to the community
Building friendships with peers
Building relationships with counselors

Question 5: How would you describe participant’s Jewish identity? Check the box that best applies. *
 


Are you a returning participant? *
Question 7: How much have the participant’s independent skills improved because of last summer’s experience at Summer@ETTA? 
 

Question 8: In what area do you feel that Summer@ETTA contributed to the participant’s growth the most? (circle a number 1-5, with 1 being no growth and 5 very much growth)
 12345
Exercise
Sports
Arts and Crafts
Singing
Dancing
Jewish Education
Shabbat Celebrations
---- Independent Living Skills ----
- Dental Hygiene
- Shopping
- Cooking
- Social etiquette
- Self-advocacy
Social Interaction/Conversation
Field Trips
Giving back to the community
Building friendships with peers
Building relationships with counselors


Question 10: How has Summer@ETTA impacted your family’s Jewish involvement? Check all answers that apply and please elaborate in the comments below. Because of our child’s experience at Summer@ETTA:


Question 12: Would you recommend Summer@ETTA to a friend? Check best answer.


Thank you!