Telephone number: (+country/area code)

First name:
Surname:
Address:
Postal(ZIP)code:
City:
Province/Region:
County:
Telephone number: (+country/area code)
Mobile number: (+country/area code)
Contact availability schedule:
Fax number:
Email address:
MSN/Yahoo/Skype:
Date of birth:
Place of birth:
Age:
Nationality:
Height(cm):
Weight(kg):
Gender:	Female Male
Civil status: (can be more than 1 option)	Single Married Divorced Living with parents Living with parent Living on your own
Drivers license:
International drivers license:	No Yes, sinceЎ­Ў­
How often do you drive: (days per week)	No Yes
Do you feel comfortable driving in snow?
Passport number:
Date issuing passport:
City issuing passport:
Nearest International airport:	Option 1: Option 2:
Religion/Spiritual practice:
Way of practicing religion:
Special needs for Religion: If yes, please explain:	No Yes
Health information:
Smoking:	No Yes On occasions only
Drink Alcohol:	No Yes On occasions only
Tattoos:	No Yes,explain:
Piercings:	No Yes,explain:
Medication:	No Yes,explain:
Health restrictions:	No Yes,explain:
Diet:
Allergies:	No yes,explain:
Vegetarian:	No Yes
If yes, are you willing to prepare meat for the family?:
Do you, or have you ever suffered from:
Asthma, bronchitis, persistent cough or other chest condition	Yes,explain /No
Shortness of breath, palpitation, high blood pressure or any heart condition	Yes,explain /No
Rheumatic fever or rheumatism	Yes,explain /No
Persistent indigestion, ulcer other stomach bowel problem, gall stones or jaundice	Yes,explain /No
Bladder or kidney trouble or stones	Yes,explain /No
Varicose veins, phlebitis or piles	Yes,explain /No
Hernia (rupture)	Yes,explain /No
Fits, faints, depression, anxiety state or nervous breakdown	Yes,explain /No
Headache or migraine	Yes,explain /No
Any disorder of the eyes, ears, nose or throat	Yes,explain /No
Any disease of the nervous system	Yes,explain /No
Arthritis, backache or disc trouble	Yes,explain /No
Skin disease or dermatitis	Yes,explain /No
Diabetes	Yes,explain /No
Eyesight problems or visual disturbances not corrected by glasses or contact lenses	Yes,explain /No
Hearing impairment requiring assistance or special equipment at work or any recurrent or persistent	Yes,explain /No
Allergies to dusts, chemicals, foods, drugs or other substances	Yes,explain /No
Do you have, or are you a carrier of:
Hepatitis A/B/C	Yes,explain /No
HIV or AIDS	Yes,explain /No
Tropical disease e.g. malaria, typhoid etc.	Yes,explain /No
Tuberculosis	Yes,explain /No
Persistent MRSA	Yes,explain /No
Absent in course or work due to disease in the past one year:	Yes,explain /No
Any causes affect you to be Au pair in China such as disease and others.	Yes,explain /No
Can you swim:	No Yes
Certificate:	No yes,explain:
Are you secure enough to swim with children:	No yes,explain:
Can you cycle:	No Yes
How often do you cycle: (day per week)
Are your cycling skills good enough to take a child with you on the bike?	No Yes After a short period of practice
Hobbies and interests:
Level of Language(s)Јє
Chinese/Mandarin None	Poor	Fair	Good	Excellent	Native
English None	Poor	Fair	Good	Excellent	Native
Spanish None	Poor	Fair	Good	Excellent	Native
French None	Poor	Fair	Good	Excellent	Native
German None	Poor	Fair	Good	Excellent	Native
OtherЎ­Ў­ None	Poor	Fair	Good	Excellent	Native
Level of Education (add name,for example,Business management, Arts, Sciences etc.)	High school-Level: Diploma: No Yes University-Name study: Diploma: No Yes
Frist Aid certificate:	No Yes
Extra information/ certificates you would like to add:
Family info
Present occupation:	Work: Study: Other,explain:
Does your mother work?	Yes No
Does your father work?	Yes No
Which profession has your mother:
which profession has your father:
Family info
How is your relationship with your mother:
How is your relationship with your father:
Do you have a big family:	Yes No
How many sister(s) and brother(s) do you have (+name and ages)
Do you have many friends:	Yes No
What do your friends think about your plans to become an au pair:
Who is/are the most important person(s) in your life,and why:
Position Au Pair:
Seeking host family in country:
Earlies start date:
Lastest start date:
Shortest stay:	3 Months	6 Months
Longest stay:	6Months	12 Months
second year placement	No	Yes,preferred country:
Do you accept a host family in: (can be more than 1 option)	Capital city Big city Small city/Village Countryside

Are you able to/willing to
Take care of pets:	Yes	No	mother only father only
Di light housework:	Yes	No
Make the beds:	Yes	No
Do the dishes:	Yes	No
Cook a simple meal:	Yes	No
Shop for food:	Yes	No
Wash and Iron clothes:	Yes	No
Willing to help more than common:	Yes	No	Explain extra duties:
Are you able to/willing to:
Look after baby, age 0-2:	Yes	No
Look after child, age 2-5:	Yes	No
Look after child, age 6-10:	Yes	No
Care for a disabled child:	Yes	No
Change a diaper:	Yes	No
Prepare bottle for a baby:	Yes	No
Feed baby with spoon/fork:	Yes	No
Dress child occupied:	Yes	No
Bath a baby:	Yes	No
Help with homework:	Yes	No
Personal preference:	Yes	No
Willing to help more than common:	Yes	No	Explain extra duties:
The number of children you want to take care for:	1-2 1-3 3 or more
The age category you want to take care for: (can be more than 1 option)	3-12 months 12-24 months 2-5 years 6-10 years 10 years and up
Do you have experience with electric equipment:
Microwave:	Yes	No
Washing machine:	Yes	No
Iron:	Yes	No
Dish washer:	Yes	No
Vacuum cleaner:	Yes	No
Coffee machine:	Yes	No
Water boiler:	Yes	No
Oven:	Yes	No
Electric stove:	Yes	No
Gas stove:	Yes	No
Add equipment:	Yes	No	Explain:
Additional information:
Have you been an au pair before:	Yes No
In which country and city:
Period:	﹍-﹍-﹍until﹍-﹍-﹍
Name host family:
Contact details host family: (+country/area code)	Tel: Mobile:
Email address Host family:

How do you spend your leisure time at home:

How can you describe yourself(honest, reliale, shy,etc)

Describle why you want to become an au pair:

What are your plans for the future:

How did you find out about the au pair program:

Extra information you would like to add:

A letter to the host family

5 photos (including a family photo)

Дата добавления: 2015-08-27