| Step
2: Complete and submit the form below |
| Agency
name (if applicable) |
|
| What
country do you want to go to? |
|
| What
is the earliest date you can start? |
Day
Month
Year |
| What
is the latest date you can start? |
Day
Month
Year |
| How
long do you want to stay for? |
|
| PERSONAL
DETAILS |
| Full
Name |
|
| Are
you |
MALE
FEMALE
|
| Address |
|
| Postcode/Zip |
|
Telephone
(including area code) |
Home
Work
|
| Mobile
Number |
|
Fax
Number
(or fax number of a friend so that we can get documents and messages
to you) |
|
| E-mail
Address |
|
| Date
of Birth |
Day
Month
Year |
| Age |
|
| Height
|
Weight
|
| Colour
of hair |
Colour
of eyes |
Do
you have any visible tattoos or piercings?
|
yes no -
If so, where and what
|
| Passport
Number |
|
| Date
& Place of issue |
Date
Place
|
| Expiry
date |
Day
Month
Year |
| Nationality |
|
| Religion |
|
| Do
you regularly attend religious services? |
Yes
No |
| Father's
profession |
|
| Mother's
profession |
|
| Number
of brothers |
|
| Ages |
|
| Number
of sisters |
|
| Ages |
|
|
|
EDUCATION
|
| Please
give some information about your education. What school you have
attended, what examinations you have passed and what qualifications
you have. You can use a separate sheet if you need to. |
|
|
| What
are your future educational plans? |
|
| Do
you want to take a language or educational course in the host
country? |
Yes
No |
| Do
you have any knowledge of first aid or lifesaving? |
First
Aid Life
Saving |
| If
so, do you have any certificates? |
Yes
No |
| Have
you taken any courses related to childcare? |
Yes
No |
|
|
|
|
|
| What
is your mother tongue? |
|
| Do
you speak English? |
YES
NO |
| How
long have you been learning English? |
|
| Is
your English? |
Fluent
Good
Average
Basic
Poor |
| Do
you speak any other languages? |
YES
NO |
| Please
list languages and level of competence |
|
| Language
|
Fluent
Good
Average
Basic
Poor |
| Language
|
Fluent
Good
Average
Basic
Poor |
| Language
|
Fluent
Good
Average
Basic
Poor |
|
|
CHILDCARE
EXPERIENCE AND REQUESTS
|
| What
experience do you have with children? |
|
|
| What
ages do you have experience of? |
0-4
4-10
10+ |
| What
ages do you prefer to care for? |
0-4
4-10
10+ |
| Would
you like a family with: |
|
| One
child |
Yes
|
| Two
children |
Yes
|
| Three
or more children |
Yes
|
| Three
or more children where the mother does not work |
Yes
|
| OR
Don't
mind about the number of children |
No
|
| Are
you willing to care for a disabled child? |
Yes
No |
| Do
you have any experience of caring for a disabled child? |
Yes
No |
If so, what experience
do you have?
|
| Would
you accept a family without children? |
Yes
No |
| Would
you help with a new born baby if the mother is present? |
Yes
No |
| Would
you help look after the elderly? |
Yes
No |
|
|
DOMESTIC WORK
|
| What
experience do you have of domestic work? |
|
| Can
you cook? |
Yes
No |
| Can
you do washing and ironing? |
Yes
No |
| Can
you hoover/vacuum and dust? |
Yes
No |
| Are
you prepared to help with light domestic work? (Most families
require this) |
Yes
No |
|
PETS
|
| Do
you like pets? |
Yes
No
|
| Are
you happy to live with a family who have pets? |
Yes
No |
| If
so, would you help look after them? |
Yes
No |
| Are
you allergic to any animals ? |
Yes
No |
| Are
there any animals you do not like? |
|
|
|
HEALTH
|
| Do
you have any allergies? |
Yes
No |
| Are
you in good health? |
Yes
No |
| If
no, please explain: |
|
|
|
|
SPECIAL DIET
|
| Are
you a vegetarian? |
Yes
No
|
| Do
you eat (please select the ones you eat) |
FISH?
DAIRY
PRODUCTS?
PORK? RED
MEAT? |
|
|
HOBBIES, SPORTS AND
SPECIAL SKILLS
|
| What
are your hobbies? |
|
|
|
| Do
you participate in any sports? |
Yes
No
|
| Can
you swim? |
Yes
No |
| Do
you have a background in music or dance? |
Yes
No |
| Do
you play any musical instruments? |
Yes
No |
| Do
you have any special skills, such as horse riding, or sailing etc.? |
|
|
|
|
|
DRIVING
|
| Do
you hold a full driving license? |
Yes
No |
| When
did you get your license |
|
| How
much experience do you have? |
|
| Do
you drive regularly? |
Yes
No |
| Are
you prepared to drive in the host country once you get to know the
area? |
Yes
No |
|
|
SMOKING
|
| Do
you smoke? Yes
No |
How
many per day? |
| Are
you willing to refrain from smoking in the family's house or in
front of the children |
Yes
No |
|
|
AREA PREFERENCES
AND SPECIAL REQUESTS
|
| Would
you prefer to be in: |
COUNTRY
TOWN
VILLAGE
ANYWHERE |
| Would
you accept a village that is near a town? |
Yes
No |
| Do
you wish to be in a specific area? |
Yes
No |
|
|
| If
we cannot find a family in that area, would you consider other
areas? |
Yes
No |
Would
you consider a one-parent family where:
|
The
mother only is present?
Yes
No
The father only is present?
Yes
No |
| Are
you willing to work with families of all ethnic and religious
backgrounds? |
Yes
No |
| Do
you want to be: |
| AU
PAIR |
Yes
|
| AU
PAIR PLUS |
Yes
|
| MOTHER'S
HELP |
Yes
|
| DEMI
AU PAIR |
Yes
|
| SUMMER
AU PAIR |
Yes
|
|
|
TRAVEL
EXPERIENCE
|
| Have
you travelled to any other countries before? |
Yes
No |
| Have
you lived away from home before? (i.e. two months or more) |
Yes
No |
|
If so, where and for how
long?
|
| Have
you been to the host country before? |
Yes
No |
| Have
you been an au pair in the host country before? |
Yes
No
|
| Are you already in
the host country (in the case of au pairs changing families)? |
Yes
No |
| If
Yes what date did you come |
|
| How
long were you here for? |
|
| Please
give the name and telephone number of the family where you were (or
are) an au pair |
NAME
PHONE NUMBER
|
| Please
give the name, address and telephone number of whoever we should
contact in case of an emergency while you are in the host country (like your
parents)
|
NAME
ADDRESS
PHONE NUMBER
|
|
WHY DO YOU WANT TO BE AN AU PAIR
AND WHY HAVE YOU CHOSEN THE HOST COUNTRY?
|
|
IMPORTANT NOTICE
You
must have enough money for your journey home, or an open ticket.
You
are responsible for your own health insurance while you are in the
host county. We can supply information about insurance if you
wish.
You
must NEVER hit the children or leave them alone and unsupervised.
You are responsible for their care while the parents are away.
|
|
|
|
| |
|