KES AGENCY
Czech Republic
698 01 VESELI NAD MORAVOU, Chaloupky 574/17
Tel: 00420 533 312 716 , FAX: 00420 518 32 6766
Email:
AU PAIR APPLICATION FORM p h o t o
C O U N T R Y :
______
PERSONAL INFORMATION
Surname: Christian name:
Date of Birth
Address:
Nationality: Passport number:
Telephone number – home: Mobile: work:
E – mail: Fax:
When do you wish to arrive:
How long for:
Do you have any allergies, dietary restrictions:
______
Religion: Studies/Occupation :
Knowledge of E - basic/fair/good/very good/fluent:
Knowledge of others languages :
How long have you studied language:
Do you feel able to hold a simple conversation:
Any examinations/diplomas:
Would you ask family to contact you - or do you prefer to contact family before you arrive :
______
Father:
Father´s occupation:
Mother:
Mother´s occupation:
Address on parents incl. Address:
Sisters: Ages: Brothers: Ages:
______
Can you cook? Can you iron? Can you swim?
Do you hold a driving license: How long for:
Do you feel confident enough to drive in this country ?
What are your hobbies:
What are your experiences with children, babysitting etc.:
/describe and att. 2 references and one of your character/
Do you like animals:
Do you smoke:
Do you understand that if you smoke against the wishes of the family, they are completely within their rights to ask you to leave:
Would you accept to smoke only outside the house if required:
______
CHILDCARE
Position required: Au Pair Au Pair Plus Mothers help Housekeeper Nanny
What age of children do you prefer: 0-12 months: 1-3:
3-5: over 5 yrs:
Is there any age group you will not definitely accept:
Would you accept a family without children:
Would you accept a family with handicap child? :
Would you accept a single parent family: mother/father/either:
Do you prefer a family in a town/suburbs/country:
Would you accept a family of another race/religion:
If NOT, what is NOT acceptable:
______
Would you accept a family in the country provided you were on a bus/train route or had the use of a car in order to attend language school ?
If you are coming in the summer months, do you realize that there are no classes available and you will be expected to be with the children during the day, especially if the mother is working:
Do you accept that in the summer there is no way to change a family:
Do you understand that as an Au Pair you will be expected to help with the housework i.e. hovering, dusting, laundry, ironing and babysitting and other domestic work according position:
______
Do you wish to attend language classes:
What are your reasons for being an Au Pair:
Have you had any previous employment:
Have you been an au pair before:
If YES, where and how long for:
Are you registered with another agency:
Do we have your permission to give your telephone number to another au pair :
Have you any criminal convictions :
If yes, please state for what:
Name and address of next of kin:
Signed:
______
Enclosure 1
KES AGENCY
Czech Republic
DEAR FAMILY LETTER
Signed:
Date:
Enclosure 2
MEDICAL REPORT/ ÄRZTLICHES ATTEST
Name:
Address :
Tick the appropriate box if the above mentioned person suffers from or has ever had
/ Bitte kreuzen Sie an, welche der folgenden Krankenheiten die o.g. person hatte bzw.hat:
Tuberculosis/ Tuberkulose Headaches/Migraine
Diabete/ Diabetes Asthma / Asthma
Rheumatic fever/ Rheuma Hepatitis / Hepatitis
Depression /Depressionnen Anorexia/Anorhexie
Bullmia / Billimie
If you have answered yes to any of the above please give details incuding dates if applicable / Sollen Sie etwas angekreutz haben, bitten wir Sie, die genügen Daten anzugeben:
Does the above mentioned person suffer from any allergies / Hat die o.g. person Allergien?
Penicilin/Penicillin
Hay fever/Heuschnupfen
Other drugs/Andere Medikamente
Animals/Tiere
Food aditives/Lebensmittel
Insect stings/Insektestiche
Autres /Others/Andere
If you have answered yes to any of the above please give details incuding dates if applicable / Sollen Sie etwas angekreutz haben, bitten wir Sie, die genügen Daten anzugeben:
Is her/his physical activities restricted in any way?
/ Sind die physischen Aktivitäten der o.g.Person eingeschränkt?
Is the above mentioned person currently taking medications? Nimmt die o.g. person im Moment Medikamente?
Does the above mentioned person haveany chronic or recrurring illness/ Nhat die o.g. person chronische Krankenheit?
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If you have answered yes to any of the above please give details incuding dates if applicable / Sollen Sie etwas angekreutz haben, bitten wir Sie, die genügen Daten anzugeben:
Please review the information provided over, and give your opinion of the applicants general state of health / Bitte kreuzen Sie an, in welchem gesundheitlichen Gesamtzustand sich die o.g. Person Ihrer Meinung nach befindet
Excellent/Sehr gut /Good/gut fair/befriedigend poor/Schlecht
Doctor’s name & add / Name und Adresse des Artzes:
Date / Datum: ______
Signature and stamp
Enclosure 3+ 4
KES AGENCY
Czech Republic
698 01 VESELI NAD MORAVOU
Email:
CHILDCARE REFERENCE
KINDERBETREUUNGSNACHWEIS
Lettera di referenze
Name of applicant:
Name der Bewerberin/des Bewerbere______
______
For how long did you employ the applicant / Wie lange hat die Bewerberin/der Bewerberer bei ihnen gearbeitet?
______
When did she/he lastlook after your children/Wann hat sie/er zum letzten Mal bei Ihre Kinder betreut?
______
Did she/he worked regularly or occasionaly for you/ Hat er/sie regelmaßig fur Sie gearbeitet?
______
Please,state the number & the age of your children she looked for/Bitte geben Sie Alter und Zahl der zu betreuenden Kinder an.
______
Please explain the applicant’s duties in your home. Did she/he help in the household chlore (cleaning, cooking,ironing, vacuuming, etc.).
Bitte geben Sie an, welche Aufgaben der/die Bewerberbein ihnen ausgefürt hat. Hat er/Sie Haushalt mitgehalfen (putzen, kochen, bügeln, staubsaugen, etc.)?
______
Didi the applicant live with your family? If yes, for how long? / Hat der/die Bewerberbei Ihnen gewohnt? Wenn ja, wie langue?
Enc 3/2
______
How did she/he get along with the children? Please consider the following aspects: love for children, understanding of children, responsability, maturity and ability to work with adults.
Wie kam er/sie mit den kindern zurecht? Bitte bericksichtigen Sie bei die folgende Punkte: die Kinderliebe, das Verstandnis für Kinder, das Verantwortungsgefühl, die Reife und die Fähigkeit zur Zusammenarbeit mit Erwachsenen des/der Antragsteller(s)
______
Name of employer/Name der Arbeitsgebers:
Adresse: ______
Phone:
Mobile:
Date: Signature:
Enclosure 4
KES AGENCY
Czech Republic
698 01 VESELI NAD MORAVOU, Chaloupky 574/17
Tel: +420 737 713 911, 00420 533 312 716
Email:
CHILDCARE REFERENCE
KINDERBETREUUNGSNACHWEIS
Lettera di referenze
Date:
SIGNED:
Enclosure 5
KES AGENCY
Czech Republic
698 01 VESELI NAD MORAVOU, Chaloupky 574/17
Tel: +420 737 713 911, 00420 533 312 716
Email:
CHARACTER REFERENCE
FICHE DE CARACTERE
CHARACTER REFERENZ
Name of the applicant:
Name der Bewerberin der Bewerberers :
______
For how long have you known the applicant ?
Wie langue und in welcher Funktion kennen Sie den/die Bewerbere/in?
How do you know the applican?
Von wo kennen Sie den/die Bewerberer/in?
Why would you recommend the applicant to a family abroad?
/ Können Sie den/die Bewerber/in einer Familie im Ausland empfehlen,undwarum?
What are her/his best qualities?
Was sind ihre/seine besten Qualitäten?
What are her/his weaknesses?
/ Was sind ihre/seine Schachpunkte?
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Please describe the applicant:
/ Bitte beschreiben Sie den/die Bewerbere/in.
Name of the employer:
/ Name des Arbeitgeber
______
Address/Adresse:
______
Private phone / Privattelephon:
Office phone / Beruflich Telephon:
Date / Datum: ______
Signature/Unterschrift
Enclosure 6
A G R E E M E N T
1. I, ______confirm that I have read all written materials provided by KES AGENCY and that I fulfil all creiteria. I understand that the Au Pair programme is a cultural exchange programme and not a contract of work. I am aware that being an Au Pair requires a high degree of both responsability and flexibility and that I must take my duties seriously.
2. I confirm that I have answered all questions honestly and that all information in the application is true.
3. After confirmation of placement, I shall stay in touch with my host-family and shall inform of my travel arrangements. I agree not to travel to my host-family until I have received an official confirmation of placement from KES AGENCY.
4. I shall familiarise myself with all (ifl any) visa requirements. I shall obtain necessary documents (e.g. a valid passport) prior to departure and shall not enter my host-country without a proper visa (if required).
5. I agree to cover all costs for language courses, travel to and from my host-country (unless otherwise stated in the programme guidelines) and any debt incurred (e.g. telephone bills, etc.) I shall bring emergency funds with me (as recommended by the Au Pair Agency) to pay for unforseen expenses.
6. I am familiar with and agree to abide by all programme guideline and conditions, in particular those regarding the number and distribution of working hours, au pair duties, pocket money, free time, holidays, language courses, transportation cost, insurance and the termination of an Au Pair arrangement.
7. Upon my arrival in my host-country, I shall discuss in detail with my host-family the daily or weekly routine and my and their expectations of the Au Pair programme.
8. I shall carry out my child care and light housekeeping duties with diligence. In addition to my Au pair duties, I agree to keep my room clean and neat and to make a fair contribution to the cleanliness of the common areasof my host-family home.
9. I agree to abide by all rules set by my host-family (i.e. use of the phone, internet acces, and facilities within the home, daytime and overnight visitors, curfew, smoking, etc.). During my stay I shall behave in a manner which does not reflect badly upon my host family, both Au Pair agencies or my country home.
10. I shall seek the advise of the host-family before administering any form of discipline on the children. Under no circumstance shall I hit the children or leave them alone.
11. I shall discuss with my host-family any arrangement for holidays well in advance.
12. I shall make a concerted effort to experience the culture of my host-country and to learn the language. I shall respect cultural differences and display tolerance toward others.
13. I realise that the success of my Au Pair stay depends largely on my own initiative. I shall try to integrate myself into family life and should any problem arise, communicate openly with the family and actively seek a solution.
14. If I have any problems or questions which cannot be discussed or resolved with the host-family, I shall contact the Au Pair agency in my host-country for assistance.
15. I shall make every effort to resolve any difference with my host-family. If no solution can be reached and I decide to leave the family, I agree to give 14 days advance notice. During this period, I shall perform my normal duties and receive room, board and pocket money. If I request to be placed with a new family, I realise this might involve moving to a different city.
16. I understand that I shall be expelled from the programme and must return home if: I fail to abide by this agreement or programme guideline
I falsify any information in my application (e.g. regardiing smoking, child care experience, health, tec.)
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I begin my Au Pair stay before receiving any official confirmation of placement from the Au Pair agency or a
Proper visa. I am responsible for repeated problems with several families . I disobey the laws of my host
Country.
17. I agree to leave my host-country before my visa or residence permit expires (if applicable).
18. I shall not undertake any other paid employment and will perform only those tasks related to the Au Pair programme.
19. Should I decide to cancel my application, I shall inform the Au Pair agency at once and could not expect any refund.
20. I shall notify KES AGENCY immediately if there is any changes to the information included in my application.
21. I shall not hold KES AGENCY responsible for any losses, injury or damage that may occur during my placement.
Surname & Last name: ______
Date & Place: ______
Signature : ______
Enclosure
7/ COPY OF PASSPORT
8/ COPY OF DRIVING LICENSE
9/ COPY OF NO CRIMINAL RECORD
10/ PASSPORT PHOTO
11/ PHOTOS witch children
______
How to write a letter for your potential host family
This letter should give a family a better picture of yourself, where you are coming from, your family traditions and so on. There are few ideas what you should mention in your letter:
· How old are you parents, what do they do what kind of relationship you have with them?
· Do you have brothers and sisters? How old are they, what do they do, what they like?
· Do you have families meeting, do you talk to you relatives, or you leave far away from them?
· What kind of activities does your family on weekends do you together for holiday or you have a summer house where you spend most summer?
· What is your role in a family? Do you help with younger siblings, housework, cooking or pets?
· Are you an organized person, or more casual? (Be careful what you are putting here – being tidy does not necessary mean a good thing. Some families don’t like au pair to organize them, some are irritated by untidy person. This is the most common problem in relationship between family and au pair, so be honest!)
· Can you describe yourself? Are you shy, introvert, calm, very active etc?
· What have you done so far like attend a college, wining some competition, being a member of some organization, travel and etc?
· Why do you want to be an au pair?
· What experience do you have of looking after children?
· Do you think you will be able to cope without our family, friends, girlfriend/boyfriend?
· Have you ever lived away from home?
· What do you want to gain from au pair experience?