| Name * |
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| E-mail Address * |
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| Title * |
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| Last name * |
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| Home address (including postcode) * |
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| Contact Telephone number * |
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| Host father (full name, date of birth, nationality, mother tongue) * |
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| Host Father's profession |
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| Host mother (full name, date of birth, nationality, mother tongue) * |
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| Host Mother's profession |
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| Children (names, date of birth, gender) * |
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| What is your religion? |
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| Do you have children with disabilities? * |
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| If yes, please name and describe the disability |
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| Do you smoke? * |
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| Are there other aspects of your family life which should be given consideration (e.g. vegetarian diet)? * |
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| Do you have any pets? * |
yes
no
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| If yes, which pets do you have? |
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| Which language is mainly spoken in your family? * |
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| What other language(s) do you speak? |
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| Where do you live? * |
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| Distance from your home to the nearest language school * |
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| Children's daily schedule (please state names of children, times they are at school or otherwise out of the house - sports classes etc) * |
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| Requested start date for an au pair * |
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| Minimum length of stay you require an au pair for * |
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| Maximum length of stay you require an au pair for * |
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| Are you willing to accept a male au pair? * |
yes
no
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| Would you accept an au pair that smokes? * |
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| Should your au pair hold a driving licence? * |
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| Au pair's sample time plan (please describe the au pair's working week by including working hours, usual start & finish time, duties etc) * |
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| A letter to your au pair - introduction of your family (Introduction: members of your family, your everyday life, hobbies and interests, particulars; Brief description of your town, your house and also room of your au pair; Which expectations do you have of the au pair's stay?; How do you want to facilitate the cultural exchange programme?) * |
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| please advise of convenient time to contact you |
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| Where did you hear about us * |
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