AU PAIR APPLICATION FORM

When completing the following questions, please be as flexible as possible, to enable an efficient placement.

PERSONAL DETAILS
First name Surname

Address in full: Telephone: Mobile: Earliest start date: For how long Minimum: Sex: Height Nationality Do you wish to be Au Pair or Au Pair Plus? Religion Fathers occupation: Fax: Email: Latest start date: Maximum Date of Birth Weight Passport No Au Pair Practising Mothers occupation: Au Pair plus

No. of brothers and sisters (if you have) and ages: Do you smoke?
Please answer truthfully

If so, how many per day? -

Would you agree to smoke only away from the home? Since when?

Do you have a current driving license? What driving experience do you have? Are you willing to drive in the UK? (Lessons

will be provided)

Do you have any allergies/disabilities/illness?

If yes please give details (eg diabetes, epilepsy, anorexa)

Do you follow any special diet? If yes please give details, eg vegetarian or for religious reasons

What are your hobbies/interests? Which sports do you regularly do? Can you swim? Can you play a musical instrument? How well do you speak English? Average Poor Good Basic Advanced Do you like animals?

Are you able to hold a conversation in English? Years learning? Do you wish to attend English classes Do you speak any other languages? Name and address of person(s) to contact in case of emergency Have you lived away from home for any length of time (2 months or more)? If yes, please give Have you been an Au Pair before? When and where? Do you read and write in English?

(Please send reference letter from previous family, if available)

EDUCATION/EMPLOYMENT DETAILS
Last school/ college/university attended: If employed occupation: Previous occupation: Have you any first aid certificates Do you have any professional qualifications with children?
(Please attach copies of Diplomas, etc.)

Future educational plans/future ambitions

EXPERIENCE WITH CHILDREN AND HOUSEWORK

What experience do you have of domestic work Can you cook basic food? Are you prepared to help with light domestic work? (eg. washing, ironing, vacuum, dust)

What experience do you have with children? What experience do you have with babies?

Would you take sole charge of children? Would you take sole charge of babies? Would you accept a baby if the mother were also home? What age group of children do you prefer? (Please 0-2 years 2 5 years Will you accept a: Single mother? Adult-only family? (No
be flexible)

5 years and over Single father? Whole family?

any age

children)

Will you accept a child with mild disabilities? Are you willing to live with a family with pets/animals? Are you willing to help look after the familys pets? Is there any type of family you would not consider? Will you accept a family who lives in a: Inner London Area close to London In the countryside

Outer London Another city Anywhere If so, when

Do you plan to return to your home country during your stay in the UK?

How would you best describe your personality Declaration

I hereby confirm that the information given above is true. I understand that failure to answer truthfully may lead to early termination of my position. I have read and understood the Au Pair fact sheet and wish to join the Au Pair Program. I understand that the Au Pair Agency provides an introduction between myself and a family and cannot accept any liability whatsoever for losses, expenses, injury or negligence in relation to placing me with a family in the UK.

SIGNATURE

DATE