Au Pair Application Form

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Au Pair Application Form

Au Pair’s Details

surname		first name
Male	Female	date and place of birth
Nationality		height/weight
Address		town
country		skype-nik or ICQ
passport no. valid until		Home telephone
mobile		e-mail
religion		Are you practicing?	Yes No
school qualification		professional training
professional experience		present job position
former visits abroad (country, length, kind of activity)
hobbies, interests
physical disabilities / allergies
Are you vegetarian?	Yes No	Do you have a criminal record? If Yes, please give details	Yes No
Can you swim?	Yes No	Can you ride a bicycle?	Yes No
Do you smoke?	Yes No	If Yes how many a day?
If Yes are you willing to smoke outside ONLY and NOT in the presence of the children? Yes No
Will you accept a family that smoke?	Yes No
Do you hold a driving licence?	Yes No
How long you have been driving?		Are you willing & confident to drive?	Yes No
Are you in good health?	YesNo
Do you have any allergies? If yes please give details	Yes No
Do you have any dietary restrictions? If yes please give details	Yes No
Have you ever lived abroad? If yes please give details	Yes No

Au Pair’s Preferences

In which country(ies) you would like to be au-pair?
When can you start?		Latest start date?
How long do you wish to stay or until what date?		other wishes:	months
Do you prefer to be placed in a:		City
Town	Village
Farm	Anywhere
Are you willing to take care of:	preferred	possible
0 – 1
1 – 3
3 – 6
6 – 12
Would you be prepared to look after a disabled child? yes no	mentally handicapped	physically disabled
How many children would you like to care for?		How many maximum?
Would you accept a single mother?	Yes No	Would you accept a single father?	Yes No
Would you accept a family of different religion?	Yes No	Would you accept a family of different race?	Yes No
Would you also care for pets?	Yes No	Which pets do you not like and you would not care for?
Do you wish to be a:	Au Pair	Au Pair +	Mother’s Help
Do you wish to attend language classes?	YesNo
Any special wishes?

Details about your family

Parents	mother	father
surname
first-name
occupation
Address – street, number
Town
Telephone No.
I have sister(s), aged:	I have brother(s), aged:

Details about your knowledge of foreign languages

How well do you speak the language of the target country?	1 = Poor 2 = Fair 3 = Good 4 = Very Good 5 = Excellent
1 2 3 4 5
How long have you been studying English?
How many hours per week did you learn this language?		1 = Poor 2 = Fair 3 = Good 4 = Very Good 5 = Excellent
Which other languages do you speak?
1.	2.	3.
How well do you speak these languages?	1.
2.

Au Pair’s Experience

	good	fair	little	none
looking after babies
getting children up and dressed, helping at bed time
keeping children occupied, playing etc
Preparing children's meals
Helping with homework
Bathing children
Where and over what period of time did you gain this experience?
Have you been an Au Pair before? If yes please give details	Yes No
Do you have any formal childcare qualifications? If yes please give details	Yes No
Please be honest in answering all cases of this questionnaire. Several au-pairs have been send home because of false information.		good	fair	little	none
cooking
ironing
cleaning
laundry
other relevant experience

Other

How will you travel to your host country?	Fly	Bus
Have you registered with any other au-pair agency?	Yes No
I agree that my address will be passed on to other au-pairs	YesNo
I completed this application form without any help.	Yes No
I got help to fill in this form by:
How did you learn about our agency?
With my signature I commission the Au-pair-Agency to find a family for me and accept the publishing of my photo on the internet. I inform the agency when I have decided for a family or I am not longer interested to be au-pair.
I fully understand the Agency’s conditions, further more, I hereby confirm that the information given above is true. I understand that the Agency provides an introduction between myself and a family and is not liable under any circumstances for any loss, damage or expense (including travel expenses) incurred myself. By signing this document, I agree to the above-mentioned terms and conditions.
_____ ________________ place, date	______________________________ signature
I understand that failure to answer truthfully may lead to early termination of my position.

Дата добавления: 2015-11-04