Au Pairs Application Form

APPLICATION FORM

Personal Details
Surname:
First Name:
Address:
Address2:
City:
Post Code:
Country: (if your country is not on the list, you cannot be registered as an au-pair)	Andorra Austria Belgium Bosnia Bulgeria Croatia Cyprus Czech Republic Denmark Estonia Faroe Islands Finland France Germany Greece Greenland Hungary Iceland Ireland Italy Latvia Liechtenstein Lithuania Luxembourg Macedonia Malta Monaco Netherlands Norway Poland Portugal Romania San Marino Serbia Slovak Republic Slovania Spain Sweden Switzerland Turkey United Kingdom
Telephone:
Mobile:
Fax Number:
E-mail Address:
Skype ID
Place of Birth:
Date of Birth:
Age:
Weight:
Height:
Gender:	Male Female
Nationality:
Ethnic Origin:
Religion:
Do you practice it:	Yes No
Visa Expiration:
Marital Status:	Single Married Separated Divorced Widowed
Father’s Name:
Father’s Occupation:
Mother’s Name:
Mother’s Occupation:
Name and Age Brothers & Sister:
I’d like to be:	Live In Live Out
Date Available:
Minimum length of stay (in months):
Maximum length of stay:
I prefer to be in:	Town Countryside No Preference
Education
Education and Diplomas:
Additional Qualification:
Languages Knowledge: (Write the language under the level) Basic Fair Good Fluent
Childcare Experience
Have you been an Au Pair before?             (If yes, please tell us when, where, for how long and ages of children) Yes No Do you have any childcare experience? (Please describe giving type of care, ages of children, etc) Yes No What is your main reason for becoming an Au Pair? (Please use as many words as possible) Are there any activities you enjoy that would be applicable to the children (Ex. biking, swimming, drawing, painting, cooking, etc?)
More Information about you
Do you have a full driving license?	Yes No
When did you get your driving licence?
How often do you drive?	Daily Once a Week Occasionally Rarely
Could you drive an automatic car?	No Yes, Beginner Yes, Expert
Would you be happy to drive abroad?	Yes No
Do You smoke?	Yes No
If you Smoke, how many cigarettes a day?
Would you be willing to smoke only outside the house and never in front of the children?	Yes No
Would you be willing to give up smoking?	Yes No
Are you taking any medication? (If yes, please give details) Yes No
Are you vegetarian?	Yes No
If yes, would you live with a family who was not vegetarian, and help them cook fish/meat?	Yes No
If no, would you live with a family who was?	Yes No
Do you have any allergies?                  (If yes, please give details) Yes No
Do you have any dietary requirements? (If yes, please specify) Yes No Do you have any tattoos or piercing? (If yes, please give details) Yes No
Previous employment
Current employment
What are you interests and hobbies?
Can you swim?	Yes No
Do you like sports?	Yes No
Do you practice any sports? (If yes, please give details) Yes No
Do you have any experience in first aid?	Yes No
How would you describe your character? Polite Patient Mature Reliable Adaptable to new situations Responsible Outgoing Family oriented Flexible Caring Friendly Hardworking Shy Kind Cheerful
Placement Requirements
Preferred Area	City Town Village Countryside No Preference
Length of stay
Earliest starting date
Latest starting date
Would you be willing to extend your stay?	Yes No
(If yes, for how long?)
Age group of children you could look after	0-2 2-5 5-10 10+ All Ages
Number of children you could look after	1 2 3 4 No Preference
Would you accept a family with disable children?	Yes No
Would you accept a family with learning difficulties children?	Yes No
Would you accept families without children?	Yes No
Would you accept a single mother family?	Yes No
Would you accept a single father family?	Yes No
Would you accept an elderly person?	Yes No
Would you accept a family of a different ethnic origin?	Yes No
Would you accept a family of a different religion?	Yes No
Do you like animals?	Yes No
Is there any animal you would refuse to look after?	Yes No
Would you be willing to do the following duties?
Help with cooking	Yes No
Cooking for children	Yes No
General housework	Yes No
Laundry	Yes No
Ironing	Yes No
Grocery Shopping	Yes No
Supervise homework	Yes No
Bathing children	Yes No
Any other duties related to children	Yes No
Caring for pets	Yes No
Do you want to attend language lessons?	Yes No
If you are coming in the summer months, do you realize that there are no classes available and that you will be expected to be with the children during the day, especially if the mother is working? Yes No
Do you accept that in the summer there is no way to change a family?	Yes No
Do you have a Criminal Record? (If yes, please give details) Yes No
Name and contact details of a person to contact with in case of an emergency
Is there any other information you feel would be relevant to your application which might help us in finding you the right family
Preferred way of contact
Telephone Email MSN Skype   References: 1st Reference 2nd Reference Name: Address: Telephone (Mobile): How many children: Age of children: How long did you work for the family?: Are you human? 1+3=
I HAVE READ AND FULLY UNDERSTOOD EVERY QUESTION IN THE ABOVE APPLICATION FORM AND I HAVE ANSWERED THESE QUESTIONS IN FULL AND TRUTHFULLY. I accept the terms and conditions of business.* Please scan and email your photo, identification, proof of address and references from places worked and/or character references to customerservice@at2aupairs.com.