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   - Available Au Pair Candidates
   - Programme Fees
   - Terms and Conditions
   - FAQ
   - Contact
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Family Application Form
    
  
First name:Street:
Surname:City:
  Post code:
Phone:Mobile:
Email:  
    
Mother's occupationNationality:
Father's occupation  
    
 Family status Practicing religion
  Couple
Single mother
Single father
Divorced
Widowed
Same sex couple
Other		  No
Christian
Jewish
Muslim
Hindu
Do not want to say
Other
    
Do you speak only English at home? If No, specify languages:
  Yes  No 
    
First names/Age/Sex of children?  
1st child name2nd child name
1st child age2nd child age
  Male  Female  Male  Female
    
3rd child name4th child name
3rd child age4th child age
  Male  Female  Male  Female
    
5th child name  
5th child age  
  Male  Female  
    
Are you expecting a new baby? If yes, when:
  Yes  No 
    
Do you have any pets? 
Does any member of your family smoke?  Yes  No
Where do you live? 
    City / Big town
Busy Residential
Quiet Residential
Rural Area
Nearest city/town? 
And how far is it? (in miles) 
    
Nearest language school? 
And how far is it? (in miles) 
    
Have you had an Au Pair before?  Yes  No
    
Will the Au Pair have her/his own bedroom?  Yes  No
Give more details, if you wish:  
  
Does your family follow any special diet?  Yes  No
If Yes, what kind of diet:   
  
Timetable and the hours the Au-Pair would be expected to work  
Per weekMonday
  Tuesday
  Wednesday
  Thursday
  Friday
  Saturday
  Sunday
    
Pocket money (£ per week)? 
    
Any other benefits? 
    
Duties of the Au Pair (please describe)  
  
Special interests and hobbies of the family?  
  
  
Type of Au Pair required?  
  Live in
Live out
Any		  Au Pair
Mother`s Help
Nanny
Cleaning only
Care for Elderly only
Any
    
Au Pair gender preferred? Au pair nationality preferred?
  Any
Male
Female		  Czech
Slovak
Polish
Hungarian
Other
    
Au pair length of stay reguired?  not more than 3 months
not more than 6 months
more than 6 months
Please give more details if you wish 
    
Ideal start date 
    
Minimum age of Au Pair? Swimming ability of your Au Pair?
  17 - 20
21 - 24
25 - 27
27+		  strong swimmer
competent swimmer
not important
    
Do you need Au Pair with a valid driving licence? Would you accept smoker?
  Yes
Essential
Preffered
No		  Yes
No
    
Please include any other details which you think might assist us in finding the right Au Pair for you  
 
    
  
    
ADD.1: Please include contact information of a person / companythat we could contact for further reference (employer, neighbour, church, family friend,(ex Au Pair, ex-Nanny etc.)  
Reference name  
Reference phone/mobile  
    
ADD.2: You can include your family pic if you wish. The photo should be in .jpg formate and should not exceed 1024 kB  
  
    
  
The above information is complete and true.  
    
I agree to TERMS AND CONDITIONS OF BUSINESS  Yes
    
2012-02-06 16:29:33 Signature
    
  

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