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 Joining Progr:
Medical Information for Children:
Significant Medical Issues or Allergies:

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

Child's Name: Year Level:
Child's Name: Year Level:


What subjects need to be worked on?


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
  • 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 my child will be absent, I will notify the Yad L'ezra iVolunteer coordinator by lunchtime of the day my child is expecting to meet.
  • Volunteers will meet my child at a pre-established documented location.
Signature Parent: (please type name)