| YOUR
BASIC INFORMATION |
|
First Name |
|
Last
Name |
|
| Address |
|
Town/City |
|
| State/County |
|
Postcode/Zip |
|
| Country |
|
Email
Address |
|
| Mobile
Tel. No. |
|
Home
Tel. No. |
|
| Age |
|
Date
of Birth (DD/MM/YYYY) |
|
| Gender |
Female
Male |
Nationality |
|
| Religion |
|
Ethnic origin |
|
|
Can
you drive?
|
Yes
No |
How
long have you held a license for? |
|
| Criminal
record? |
Yes
No |
Do you smoke? |
Yes
No |
| What
is your current job/occupation? |
|
If
you are/have been a student, what are/did you study? |
|
|
Father's
job
|
|
Mother's
job |
|
| Brother's
age(s) |
|
Sister's
age(s) |
|
Please
describe your your host country language ability
|
|
If
you can speak another language, please give details. |
|
| YOUR
PREFERENCES |
| Where
do you wish to stay as an au pair (your "host country")? |
|
How
long do you wish to stay in your host country? |
|
| What
is the earliest date you can start? (DD/MM/YY) |
|
What is your latest start date? (DD/MM/YY) |
|
| State
if you would accept a family living in: |
|
Do
you like pets? |
Yes
No |
| Will
you accept a... (check
the relevant box): |
Which
ages of children do you prefer to care for (check
the relevant box)?
|
|
single Mother |
family from a different religion |
0-2 yrs |
6-10 yrs
|
|
single Father |
family from a different ethnic origin |
2-4 yrs |
10+ yrs |
|
disabled child |
|
4-6 yrs |
|
| Are
you capable of assisting with the following (check
the relevant box)? |
Cooking for child
|
Laundry for child
|
Ironing for child
|
Food shopping
|
|
Cooking for family |
Laundry for family |
Ironing for family |
Light housekeeping |
| HOBBIES / INTERESTS
|
| Which
of the following do you have experience in or enjoy? (Check the relevant boxes.) |
Worked with babies
Worked with pre-school
Worked with older children |
Cooking
Arts and Crafts
Dancing |
Outdoor Activities
Computer Literate
Musical Abilities |
Twin Experience
Tutor Child
City driving |
| I
consider myself to be... (check the relevant boxes) |
|
Upbeat and Positive
Quiet and Reserved |
Formal
Casual |
Well Organized
Warm and Loving |
Responsible
Outgoing |
| Can
you swim? |
Yes
No |
|
|
| MEDICAL
HISTORY |
|
Are you undergoing any treatment/check-up due to injury, handicap or physical disorder? |
|
If yes, please give details:
|
|
Do you use any medication regularly? |
|
If yes, please give details:
|
|
Do you suffer from any allergies? |
|
If yes, please give details:
|
|
Do you require a special diet? |
|
If yes, please give details:
|
| LETTER
TO THE FAMILY |
| Please write a letter to your prospective family in the language of your 1st-choice host country, including why you want to be an au pair; what you would like to achieve during your stay; and why they should choose you. |
|
|
| Please attach your photograph,
here (must be .gif, .jpeg, .bmp, or .png formats.) |
PHOTO
|
|
Please choose a password, to enable you to access
family details on-line. (At least 6 characters, and no more than 12 characters.
Spaces are not allowed.) |
| Password |
|
Verify
password |
|