Summer@ETTA Participant Application

Summer 2023

June 26-July 28, 2023

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!

$150 Non Refundable Registration Fee, (does not count toward tuition.)

Please see below for cancellation policy.

Please be advised program changes and/or closures may occur due to COVID-19 and/or other medical emergencies. No Refunds will be given.

PARTICIPANT INFORMATION

Date *

First Name *

Last Name *

Gender *

Birth Date *

Address 1 *

Address 2

City *

State *

Zip *

Phone *

Cell Phone *

Email Address *

Name of Regional Center *

Name of Regional Center Caseworker *

Phone number/email *

PARTICIPANT’S PARENT OR GUARDIAN INFORMATION

Father's Information

First Name *

Last Name *

Is Father's address same as above? *

Yes

No

Address 1 *

Address 2

City *

State *

Zip *

Phone *

Cell Phone *

Email Address *

Mother's Information

First Name *

Last Name *

Is Mother's address same as above? *

Yes

No

Address *

City *

State *

Zip *

Phone *

Cell Phone *

Email Address *

PARTICIPANT FAMILY INFORMATION

Emergency contact (if parents/guardians cannot be reached)

First Name *

Last Name *

Relation to participant *

Cell Phone *

Email *

Family synagogue affiliation (if any) *

Participant’s current school or day program

Name *

Contact person *

Address *

City *

State *

Zip *

Phone *

Email *

MEDICAL HISTORY

Please list any illnesses, allergies, or pertinent medical information regarding this participant: *

Is participant currently taking any medication? If yes, please list each one: *

Will participant need to take any medication during Summer@ETTA hours? If yes, please explain: *

Will participant need a reminder or supervision? *

EMERGENCY AND MEDICAL INFORMATION

Primary Care Physician

Practice Name *

Phone *

Doctor's First Name *

Doctor's Last Name *

Address 1 *

Address 2

City *

State *

Zip *

Phone *

Cell Phone *

Email *

Medical Insurance Carrier and Policy Number *

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, video 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 13034 Saticoy Street, North Hollywood CA 91605

I consent to this photo release. *

Name (print) (This authorization is only to be signed by a person who is legally able to sign on his or her own behalf, pursuant to the Health Insurance Portability and Accountability Act of 1996 and its implementing regulations (HIPAA) and applicable California law.) *

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

clear

Date *

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 13034 Saticoy Street, North Hollywood CA 91605

Name (print) *

I consent to this photo release. *

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

clear

Date *

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 ($550 week). PLEASE NOTE: PRIORITY IS GIVEN TO THOSE WHO ATTEND ALL 5 WEEKS. *

TOTAL NUMBER OF WEEKS ATTENDING SUMMER@ETTA *

Cancellation Policy

No cancellation fee prior to June 1st.
25% cancellation fee between June 1st and June 20th.
50% cancellation fee after June 21th.
No refund after the start of Summer@ETTA

I understand that payment of $550 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 $550 per week per participant. I understand that final amount, schedule of payment, and method of payment will be determined upon receipt of this application.

**$150 Non Refundable Registration Fee, does not count toward tuition.**

*Please be advised program changes and or closures may occur due to COVID-19 and or other medical emergencies.* *No Refunds will be given.*

PAYMENT OF REGISTRATION FEE

Regardless of the number of weeks attending, a $100 registration fee is required to complete this application.

*

Cash

Check(s) made out to ETTA

Credit Card (Visa or MasterCard)

Credit card info will be collected on next page (after clicking "continue")

$150 Non Refundable Application Fee *

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 $150 fee.

Name of Responsible Party *

Address 1 *

Address 2

City *

State *

Zip *

Phone *

Cell Phone *

Email Address *

APPLICATION FOR FINANCIAL ASSISTANCE

Do you wish to apply for financial assistance? *

Yes

No

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.

Name of participant *

Participant’s special need *

Name of Parents *

Phone *

Email Address *

Number of dependents in the family *

Signature of Parent *

Please give a brief explanation of your financial situation and of the amount of the weekly fee you are able to pay: *

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).

Date

Client Signature

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!

Name *

Date *

Email Address *

Relationship to participant *

Parent

Sibling

Grandparent

Other Other

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

Returning participant

Family of previous participant

Family of previous counselor

We have friends who were participants

We have friends who were counselors

Referral (by whom?) Referral (by whom?)

Comments:

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. *

Comments:

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: *

Comments:

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) *

	1	2	3	4	5
Exercise	1	2	3	4	5
Sports	1	2	3	4	5
Arts and Crafts	1	2	3	4	5
Singing	1	2	3	4	5
Dancing	1	2	3	4	5
Jewish Education	1	2	3	4	5
Shabbat Celebrations	1	2	3	4	5
---- Independent Living Skills ----	1	2	3	4	5
- Dental Hygiene	1	2	3	4	5
- Shopping	1	2	3	4	5
- Cooking	1	2	3	4	5
- Social etiquette	1	2	3	4	5
- Self-advocacy	1	2	3	4	5
Social Interaction/Conversation	1	2	3	4	5
Field Trips	1	2	3	4	5
Giving back to the community	1	2	3	4	5
Building friendships with peers	1	2	3	4	5
Building relationships with counselors	1	2	3	4	5

Comments:

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

Comments:

Question 6: In your own words, what do you hope the participant will get out of his/her experience this summer? *

Are you a returning participant? *

Yes

No

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

Comments:

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)

	1	2	3	4	5
Exercise	1	2	3	4	5
Sports	1	2	3	4	5
Arts and Crafts	1	2	3	4	5
Singing	1	2	3	4	5
Dancing	1	2	3	4	5
Jewish Education	1	2	3	4	5
Shabbat Celebrations	1	2	3	4	5
---- Independent Living Skills ----	1	2	3	4	5
- Dental Hygiene	1	2	3	4	5
- Shopping	1	2	3	4	5
- Cooking	1	2	3	4	5
- Social etiquette	1	2	3	4	5
- Self-advocacy	1	2	3	4	5
Social Interaction/Conversation	1	2	3	4	5
Field Trips	1	2	3	4	5
Giving back to the community	1	2	3	4	5
Building friendships with peers	1	2	3	4	5
Building relationships with counselors	1	2	3	4	5

Comments:

Question 9: Was the participant’s improvement immediate and sustained? Or did the improvement diminish over time?

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:

Comments:

Question 11: Has the Summer@ETTA program affected the rest of your family in any other way – did any of your other children participate as counselors, did the general household mood improve while Summer@ETTA was in session, did ETTA connect you with additional resources, or any other result?

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

Yes

No

Why or why not (optional)

Question 13: If you could make any changes to Summer@ETTA, what would they be?

Question 14: In your own words, what did Summer@ETTA mean to you, the participant, and your family?

Summer@ETTA Participant Application

*Please be advised program changes and/or closures may occur due to COVID-19 and/or other medical emergencies. No Refunds will be given.*

PARTICIPANT INFORMATION

PARTICIPANT’S PARENT OR GUARDIAN INFORMATION

Father's Information

Mother's Information

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.

SUMMER@ETTA FEE AGREEMENT

Cancellation Policy

APPLICATION FOR FINANCIAL ASSISTANCE

FOR SLS CLIENTS ONLY

Summer@ETTA Intake Survey

Thank you!

Please be advised program changes and/or closures may occur due to COVID-19 and/or other medical emergencies. No Refunds will be given.