AU-PAIR APPLICATION FORM
Placement
First date available to start (dd/mm/yy)______Last day available to start______
Length of placement______
Where would you like to go?: Spain France Holland Belgium Germany
Personal details
Last name ______First name______
Address
______Postcode______
City/Town ______Country______
Home tel. no. ______Work tel. no.______
E-mail address______
D.O.B. ______Place of birth ______Age______
Nationality ______Passport no.______
Date and place of issue ______Expiration date______
Height ______Weight______
Are you willing to live in a family with animals?______
Would you be willing to live with a single-parent family?______
If so, which do you prefer? Male Female No preference
Have you ever lived away from home for any length of time (i.e. 2 months or more)? Givedetails
______
Religion
What is your religion?______
Do you regularly attend religious services?______
Would you accept a host family of a religion different to your own?______
Smoking
Do you smoke? ______How many cigarettes per day?______
If you smoke, are you willing to refrain from smoking in the host family’s house or in the
presence of children?______
Driving
Do you hold a current driving license?______
Do you have an international driving license?______
When did you receive the license? ______How much experience do you have?
Are you willing to drive in the host country?______
Details of parents / guardians / family
Parents’ address______
Parents’ tel. no. ______Parents’ e-mail______
Father’s occupation ______Mother’s occupation______
Other family members Brothers Age Sisters Age
______
______
______
Contact person in case of emergency (if other than parents)______
Education and qualifications
School attended______
Examinations______Qualifications______
______
______
Future educational plans______
Do you have knowledge of first aid or life savings?______
Do you have any certificates?______
Have you taken any course related to child care?______
Employment record
Past employment______
Present employment______
Length of notice required______
Experience with children
Do you have experience with
newborns aged 9-12 months aged 1-3 years aged 3-6 years
6-10 years older than 10 years?
How often (frequency)?______
Do you have experience with disabled children?______
Have you ever been an au-pair before?______
If so, in which country and for how long?______
Preferences
Are you willing to care for a disabled child?______
Age group you prefer to work with
newborns aged 9-12 months aged 1-3 years aged 3-6 years
6-10 years older than 10 years?
Would you prefer to be placed in a family with 1, 2, 3 or 4 children?
Would you prefer to live in a big city, a small town, a suburb or a rural area?
______
Would you be willing to work with a family with special needs children?______
Do you have any special dietary requirements? ______
If vegetarian are you willing to cook meat for the family?______
Are you willing to do light housework?______
Hobbies and interests
What are your special hobbies / interests?______
______
Do you participate in sports?______
Do you swim?______
Do you have a background in music or dance?______
Can you ride a bicycle?______
Language abilities
Mother tongue______
First foreign language Verbal skills Fluent Good Fair Poor
Number of years studied ______Certificates held______
Second foreign language Verbal skills Fluent Good Fair Poor
Number of years studied ______Certificates held______
Other languages: ______
Reasons for applying
Why do you want to be an au-pair?______
______
______
______
______
______
Why do you want to travel to SpainFrance Holland Belgium Germany__
______
______
______
______
Would you like to do a language course? (-5% off of normal price)
Yes (We recommend 10 h per week.) No, thanks.
Please ADD a picture of you to the application!
I have read and understood the agreement that I am signing, I promise to abide by the rules and regulations and to the best of my knowledge all the information given is truthful, accurate and correct.
Signature ______Date______
Type name______
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