AU PAIR
IN EUROPE
This application form has been approved by the Human Rights Commission
Name: Last................................... First...................................... Middle.....................................
No Smoke Declaration: Read this if you have answered "YES" to the smoking section. If you "DO" smoke, but agree not to in the Family's home or when responsible for their children, then check "YES" below. You will be expected to abide by your decision, so please consider this carefully.
Number months you are available?........................ From?..................... Until?.................................
Country you wish to travel to? (only choose one country)
Other languages you speak:
Please check off the areas that describe your interests and hobbies:
Can you swim?.......................... Lifeguard.............. Excellent.............. Good.............. Fair..............
I hereby declare that the above information is true and correct.
EMERGENCY INFORMATION
Mother's name...........................................................................................................................
DOCTOR'S REPORT
Patient's complete name...............................................................................................................
I have examined the patient named above and find her/him free of any infectious diseases and medically able to travel abroad and participate in the Au Pair in Europe Program
Doctor's name.............................................................................. Phone ( )...................................
Permanent address & postal zip code............................................................................................
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Temporary address & postal zip code............................................................................................
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What dates are you at this temporary address?................................................................................
Home # ( )................................. Work # ( )................................ Fax # ( )....................................
Are you between the ages of 18-30?..............................................................................................
Completed education ..................................................................................................................
Special sertificates: C.P.R....................... First Aid.......................... Childicare.............................
Nursing................... Cooking...................... St. John's..................... (attach copies of certificates).
Do you have a license?.................... Drive automatic?.................... Drive standard?.....................
Drivers Licence # ....................................................................... (attach a copy of driving regord)
Passport # ................................................ Valid until............................................. (attach copy)
Do you hold a passport for another country? Yes......................... No........................ (attach copy)
Country ..................................... Passport # ....................................... Valid until ...........................
Do you smoke? Yes............ No............ How many per day? ...........................................................
Yes................... No...................
France............ Switzerland............ Holland............ Germany............. Spain............ U.S.A.............
Sweden............. Bermuda............. Austria............. Belgium.............. Italy............. Finland.............
Norway................ Denmark................. Australia................. England................. Greece.................
Will you live in: Small Town................. City................. Country................. Resort Areas.................
Your mother tongue: .....................................................................................................................
1)..................................................... Fair.......... Good........... Fluent.......... Read.......... Write..........
2)..................................................... Fair.......... Good........... Fluent.......... Read.......... Write..........
3)..................................................... Fair.......... Good........... Fluent.......... Read.......... Write..........
Cooking..... Sewing..... Knitting..... Needlepoint..... Handicrafts..... Dance..... Writing..... Reading..... Artwork...... Photography...... Swimming..... Sailing..... Riding.... Tennis.... Squash.... Racquetball..... Bicycling.... Gymnastics..... Drama.... Skating..... Skiing.... Cross Country.... Downhill..... Jogging.... Stamp/Coin Collecting.... Music.... Piano.... Guitar.... Singing.... Other...........................................
Do you like pets?............................... Are you afraid of any animals?...............................................
Are you allergic to anything?..........................................................................................................
Have you had exposure to a foreign country? Yes................................... No...................................
If YES, please explain:.................................................................................................................
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How will you manage the language barrier with your host family and children?....................................
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Present employer name:.................................................................................................................
Address........................................................................ Phone ( )...................................................
Previous employer name:................................................................................................................
Address........................................................................ Phone ( )...................................................
Please check off which of the following you are confident in doing:
Care of babies 0-3 months................................. Care of babies 3-13 months....................................
Changing diapers.............................................. Preparing food for babies........................................
Children, ages 1-5............................................ Children, ages 5-10.................................................
Children, ages 10 & up........................................ General housework..............................................
Preparing snacks & lunches.................................... Preparing special diets.....................................
Preparing simple family dinners..................................... Grocery shopping....................................
Do you like to gourmet cook/bake?.............................. Laundry.................... Ironing....................
Sewing/mending clothes.......................... Keep children occupied with activities.............................
Pet care................................ Take children to extra-curricular activities.......................................
Looking after semi-invalid....................................... Looking after invalid....................................
Will you accept a position with a single mom?............................. Single dad?................................
Are you prepared to administer medication with instruction, such as insulin needles/pills etc?
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Will you take a family who smokes, even if you don't?...................................................................
How would you handle a child who is not behaving?......................................................................
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What are your expectations of your host family?.............................................................................
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What would you anticipate your duties and routine to be?................................................................
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Do you have any experience with mentally or physically challenged children? Yes........... No...........
If YES, please explain?................................................................................................................
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Other comments you wish to make:...............................................................................................
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Date............................................ Signature..............................................
Profession/occupation................................................................................................................
Company name & address..........................................................................................................
Company Phone ( )....................................... Company Fax ( )...................................................
Home address............................................................................................................................
Home Phone ( )....................................... Home Fax ( ).............................................................
Father's name............................................................................................................................
Profession/occupation................................................................................................................
Company name & address..........................................................................................................
Company Phone ( )....................................... Company Fax ( )...................................................
Home address............................................................................................................................
Home Phone ( )....................................... Home Fax ( ).............................................................
Patient's date of birth................................ Is your patient allergic to anything? Yes.......... No..........
If YES, describe & explain medication..........................................................................................
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Immunization: explain & give dates of vaccination..........................................................................
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Other medical information that is pertinent to your patient participating in the "Au Pair in Europe"
Program:...................................................................................................................................
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Address.........................................................................................................................................
Doctor's signature................................................................................ Date...................................
Doctor's stamp: