Application form

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Application form
please read Au Pair Programme Guidelines before completing this form

Name *
E-mail Address *
Type of Au Pair Programme (Au Pair, Au Pair Plus and/or Mother's Help / Nanny) *
Surname *
Home address *
City *
Postcode *
Country *
Are you single? *	yes no
Passport number *
Home telephone no (including international dialling code) *
Mobile number (including international dialling code) *
Best time to call you *
Nationality *
Date of birth (dd/mm/year) *
Driving licence *	yes no
If yes, since when
If yes, how often do you drive?
Do you have any objections of driving abroad?	yes no
Religion *
Do you practice your religion? *	yes no
Do you smoke? *	yes no
If yes, how many cigarettes per day?
Do you have any allergies? *
Do you have any health problems? *
Do you have any dietary restrictions? *
Are you a vegetarian? *	yes no
Can you swim? *	yes no
Other sports
Do you like animals? *	yes no
Do you have any brothers? If yes, how many and what are their ages? *
Do you have any sisters? If yes, how many and what are their ages? *
Your father's profession *
Your mother's profession *
Have you ever lived away from home for at least 2 months? *	yes no
When would you like to start as an au pair? *
Minimum length of stay *
Maximum length of stay *
Which country would like to go to as an au pair? *
Your estimated knowledge of English *
Your estimated knowledge of German
Your estimated knowledge of French
Do you speak any other languages? If yes, which and what is your estimated knowledge in these languages?
How many years have you studied English? *
How many years have you studied German?
How many years have you studied French?
If you speak any other languages, how many years have you studied them?
Have you passed any international language exam? *
Do you have any experience of teaching languages? *
Level of completed education *
Please give the name of your most recent educational body / subject(s) of study *
Your present occupation *
Do you wish to attend an English course in your host country? *	yes no
What are your educational plans or other on completion of the au pair stay? *
What are your hobbies and interests? *
Brief description of all the jobs you have done, dates of employment and duties *
Have you worked as an au pair before? *	yes no
If yes, in which country and how long?
Your childcare experience: siblings / family *	yes no
Your childcare experience: day-care *	yes no
Your childcare experience: baby-sitting *	yes no
Your childcare experience: camps *	yes no
Your childcare experience: au pair / nanny *	yes no
Your childcare experience: tutoring / teaching *	yes no
Please indicate which skills you have relating to childcare (cooking, first aid, nurse training, life guarding, newborn classes, child development) *
Please provide details of all the duties you have undertaken with children *
Do you have experience with: babies (under 2 yrs) *
Do you have experience with: toddlers (2 - 4 yrs) *
Do you have experience with: children (4 yrs+) *
Would you accept a family with: babies (under 2 yrs) *	yes no
Would you accept a family with: toddlers (2 - 4 yrs) *	yes no
Would you accept a family with: children (4 yrs+) *	yes no
Do you have experience with handicapped children? *
Would you take care of a handicapped child? *
Would you accept a single mother family? *
Would you accept a single father family? *
Would you accept a family with different race? *
Would you accept a family with different religion? *
Would you care for animals? *	yes no
Your capabilities in: baby-sitting *
Your capabilities in: cooking *
Your capabilities in: ironing *
Your capabilities in: caring for animals *
Your capabilities in: housework *
Your contact person in a case of emergency (full name, relationship to you, address, city, country, postcode, email, home tel number and mobile number) *
Where did you hear about us *
	I certify that all of the above information is correct and that I will inform the Au Pair Agency immediately of any difficulties encountered

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