Please note: All fields must be completed. If a field doesn't apply, type N/A.

Family Name:   

Home Phone Number: 

Are Parents Living Together  Yes    No
If no, who has custody of Children?  Mother  Father
Mother Name:   
Mother Contact Number:   
Father Name:   
Father Contact Number:   
Number of Children:   
Medical Information for Children:



Significant Medical Issues or Allergies:

Type N/A or list issue  including Reaction and/or Treatment :   

 Child 1:    Gender:   M    F Age:
 Child 2:    Gender:   M    F Age:
 Child 3:    Gender:   M    F Age:
 Child 4:    Gender:   M    F Age:
 Child 5:    Gender:   M    F Age:
 Child 6:    Gender:   M    Age:
 Child 7:    Gender:   M    F Age:
 Child 8:    Gender:   M    F Age:




Family Reference, Name & Relationship:

Phone number of a reference: 



I / We agree to the following Terms and Conditions when taking on the services of Yad L'Ezra iVolunteer students:

  • Any contact regarding additional help or changes that I require to the service provided to me will only be directed through the Yad L'Ezra iVolunteer Coordinator
  • I will never try to contact the volunteers directly, nor make any changes to the arrangement with the volunteers directly
  • I understand that for safety reasons, the parents of the volunteer will be given my name and contact details
  • I understand that at no time will there ever be a volunteer sent alone.  If for whatever reason a volunteer is unable to attend and a substitute is not available, then the session for that week will be cancelled.  The Yad L'Ezra iVolunteer coordinator will contact me prior to the session and advise me of any change
  • If I am not going to be home, I will notify the Yad L'ezra iVolunteer coordinator by lunchtime of the day I am expecting the volunteers 
  • No volunteers can ever be left alone with any male older than age 16. A mother must be present - Please contact a coordinator if this is difficult.
  • Volunteers will meet my family at a pre-established documented location.
Signature Mother: (please type name)  
Signature Father: (please type name)