PERSONAL DETAILS
First Name
Middle Name
Surname Date of Birth - Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992
Nationality Albanian Austrian Australian Belarusian Belgian Bosnian British Bulgarian Canadian Croatian Czech Danish Dutch Estonian Finnish French German Greek Hungarian Icelandic Irish Italian Latvian Lithuanian Norwegian Polish Portuguese Rumanian Russian Serbian Slovak Slovenian Spanish Swedish Swiss Turkish Ukrainian USA Other If other nationality, please specify
Mother Tongue Albanian Belarusian Bosnian Bulgarian Croatian Czech Danish Dutch English Estonian Finnish Flemish French German Greek Hungarian Icelandic Italian Latvian Lithuanian Norwegian Polish Portuguese Rumanian Russian Serbian Slovak Slovenian Spanish Swedish Turkish Ukrainian Other If other language, please specify
CONTACT DETAILS
Address Line 1 Line 2 Line 3
Town/City Province/County Postcode
Country Albania Australia Austria Belarus Belgium Bosnia-Herzegovina Bulgaria Canada Croatia Czech Republic Denmark The Netherlands Estonia Finland France Germany Greece Hungary Iceland Ireland Italy Latvia Lithuania Norway Poland Portugal Rumania Russia Serbia Slovakia Slovenia Spain Sweden Switzerland Turkey United Kingdom Ukraine USA Other If other country, please specify
Phone Number
Mobile Number
Skype Windows Live IM
Google IM E-mail
FAMILY MEMBER CONTACT DETAILS
First Name Surname
Country Albania Australia Austria Belarus Belgium Bosnia-Herzegovina Bulgaria Canada Croatia Czech Republic Denmark The Netherlands Estonia Finland France Germany Greece Hungary Iceland Ireland Italy Latvia Lithuania Norway Poland Portugal Rumania Russia Serbia Slovakia Slovenia Spain Sweden Switzerland Turkey United Kingdom Ukraine USA Other If Other Country
WHERE WOULD YOU LIKE TO GO
Please choose in which country you would like to go.
UK European Country Either
If you would like to go to another European country, please tell us which one(s).
ABOUT YOURSELF
What is your height (cm)? What is your weight (kgs)
Please give brief details of your education, how long you have studied for and which exams you have passed.
Have you got any First Aid qualifications? No Yes
If yes, please give some details.
Please give details of any other qualifications you have.
Please tell us how many years you have studied English at school/college?
Current knowledge of English Mother tongue Fluent Intermediate Basic
First other language known None Albanian Belarusian Bosnian Bulgarian Croatian Czech Danish Dutch English Estonian Finnish Flemish French German Greek Hungarian Icelandic Italian Latvian Lithuanian Norwegian Polish Portuguese Rumanian Russian Serbian Slovak Slovenian Spanish Swedish Turkish Ukrainian Other
First other language knowledge Not Applicable Mother tongue Fluent Intermediate Basic
Second other language known None Albanian Belarusian Bosnian Bulgarian Croatian Czech Danish Dutch English Estonian Finnish Flemish French German Greek Hungarian Icelandic Italian Latvian Lithuanian Norwegian Polish Portuguese Rumanian Russian Serbian Slovak Slovenian Spanish Swedish Turkish Ukrainian Other
Second other language knowledge Not Applicable Mother tongue Fluent Intermediate Basic
Do you practice a religion? No Yes Which?
Can you swim? No Yes Do you have a driving Licence? No Yes
If so, when did you get your driving licence? How much experience do you have driving? Would you be willing to drive in the UK? No Yes Do you like pets? No Yes Are you a vegetarian? No Yes
HEALTH
Do you have any special dietary requirements? No Yes If so, please explain.
Have you ever smoked? No Yes If yes, do you still smoke or if you don’t smoke anymore when did you stop smoking?
Do you drink any alcohol? No Yes If so, how often and how much?
Do you have any allergies? No Yes If yes, please explain.
Have you any other health problems like diabetes, asthma, etc? No Yes
Do you need to take any medication? No Yes
If yes, please give some details of health problems and medication.
ABOUT YOUR EXPERIENCE
Have you ever worked as an Au Pair before? No Yes
If yes, please say when, where and for how long.
Have you any other experience of looking after children? No Yes
Which age-group of children do you have experience with?
0-24 Months: No Yes
2-3 Years: No Yes
4-7 Years: No Yes
8-12 Years: No Yes
Teenagers: No Yes
Please explain any experience you have had looking after children, including their ages, whether they were boys or girls or both and the duties you carried out:
HOW MANY HOURS WOULD YOU LIKE TO WORK PER WEEK
An au pair usually works up to 25 hours per week with up to two evenings baby sitting whereas an au pair plus works up to 35 hours per week with up to two evenings baby sitting. What are you looking for? An au pair or au pair plus placement?
Which household duties are you willing to do?
Vacuum cleaning
Dusting
Washing
Ironing
Tidying
Cooking
Washing up after meals
Washing and ironing children’s clothes
Tidying/cleaning children’s rooms
Supervising homework
Supervising bedtime
Babysitting
ABOUT THE CHILDREN YOU WOULD LIKE TO LOOK AFTER
What is the maximum number of children you would like to look after?
Will you accept a family with a disabled child? No Yes
Which age-group do you prefer?
ABOUT THE HOST FAMILY
Would you like to stay in a city, town, the countryside or any particular place in the UK?
Would you accept a:
single father or a single mother host family?
host family with cats?
host family with small dogs?
host family with large dogs?
host family with other pets, such as rabbits, hamsters, etc?
ABOUT YOUR AVAILABILITY
From when are you available?
Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year 2010 2011
For how many months? Minimum Maximum
What are your hobbies? Do you play any sport?
How would you describe your personality?
Could you tell why you would like to be an Au pair in the UK?
Would you like to do a language course whilst being an Au pair? If so, do you already know which type of course you would like to follow?
Do you have any family or friends in the UK?
How did you find us? Google Search Yahoo Search MSN Search Ask Search Facebook MySpace Other Social Network Gumtree Marktplaats Jongin Kijiji Other Ads Yell Thomson Local Other Directories Told by Friends Other If Other, which one?
Please read the following statement and check the "check-box" to confirm that you have understood and agreed to the following statements:
I certify that I have understood all the above questions and that I have answered truthfully and to the best of my ability. I understand that a failure to provide accurate information could later lead to my dismissal.
I understand that I must report to Goodaupairs Ltd immediately if a placement has been agreed. All information must go via Goodaupairs Ltd.
I understand that in my role of au pair, I will live in the family home as part of the family and must respect and observe the ways of the household. I will make every effort to build a good relationship and friendship with the children of the household.
I also understand that I will be responsible for the children’s safety and conduct whenever I am charged with their care. I am willing to participate, when possible, in daily family life and to conduct myself at all times with care and consideration for others.
I agree that the information on potential host families given to me by Goodaupairs Ltd is confidential and I shall not pass any of this information (including photos) to anyone without the Agency’s consent. I agree that any information I may come across on the Family while being their Au pair or Au pair plus is also confidential and I shall not discuss or pass any of this information to anyone without the Family’s consent.
I accept that I shall inform Goodaupairs Ltd immediately if I want to leave the host family sooner than agreed and that I must give at least two week’s notice to the Family if I wish to leave.
I understand that Goodaupairs Ltd is here to help me and that I can get in touch with Goodaupairs Ltd if I have any problems or other issues I would like to discuss during my stay.
I understand that Goodaupairs Ltd endeavours to introduce me to the most suitable families, but that it is ultimately my sole responsibility to be satisfied as to the suitability of the Family.
I am not an employee of Goodaupairs Ltd and I understand that I cannot hold Goodaupairs Ltd responsible or liable for anything that happens to me during my stay with my host family.
Please check this box to indicate that you agree with the above statements
Please double check that the form is correctly filled in and that you have provided a Skype name and/or Windows Messenger Name. If you are happy to go ahead please click on this button
