Family Application Form | Au Pairs Worldwide

Family Application form for an Au Pair/Elder Pair
Personal details
Surname	*
Surname (wife/partner) if different from the above
First name (Father)	*
Date of birth	*
Please enclose copy of your passport!
First name (Mother)	*
Date of birth	*
Please enclose copy of your passport!
Street	*
City/Town	*
Zip code	*
Country	*
Home telephone no	*
Home fax no
Office telephone no	*
Office fax no
E-mail address	*
Occupation father	*
Name and address Company/Job	*
Occupation mother	*
Name and address Company/Job	*
Nationality/religion father	*
Nationality/religion mother	*
Children (names, sex and date of birth)	*
Do any of them have a disability or handicap? Please specify	*
Do any of the children go to boarding school, day school, or nursery?	*
Do both parents work?	Mother: Full time Part time No
	Father: Full time Part time No

Your home
Please give a short description of your home (no of rooms)	*
Please describe the Au Pair's accommodation (own room/own bath/TV etc.)	*
Family pets	*

Au Pair
Preferred nationality	*
Second choice	*
Type of Au Pair	Regular working hours 30 per week Au Pair plus 38 hours per week
Free days per week	*
Domestic help employed	*
Duration of stay	Summer Short term Permanent
Pocket money per month	€ 300,- € 340,-
Would you accept a male Au Pair?	yes no
Earliest starting date	*
Latest starting date	*
Length of stay required	0-3 0-5 0-8 0-12 months. Other
Will you collect your Au Pair from the airport/station when he/she arrives?	yes no
Do you require a driver	yes no
Is a car available off duty as well as on duty?	yes no
	Manual Automatic
Nearest available public transport	*
Would you refuse a smoker	yes no Other
Is the Au Pair able to invite friends (within reason) to your house?	yes no
Distance to nearest language course	*
Cost per term of local language course	*
Have you engaged an Au Pair before	yes no
If yes, how many?
How did you hear about Au Pairs Worldwide?	*

Reference
Please give the name and address of one person to whom the agency can apply for a personal reference (outside the family).
Name	*
Address	*
Telephone no	*

Agreement
I have read and accept the terms and conditions of business as specified in the brochure. I understand and accept that an Au Pair/Elder Pair introduced to me by Au Pairs Worldwide will be treated as a member of my family. I will not hold Au Pairs Worldwide liable for any loss, damage or injury caused to persons or property from any act or omission on the part of our Au Pair. I understand that, if my Au Pair's stay with me is extended. I must inform Au Pairs Worldwide immediately and I am then liable to pay any difference in fees arising from such an extension.

I agree *

Family Application form for an Au Pair/Elder Pair