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Aupair Application

First Name :
Last Name :
Street Address :
City :
Country :
Date of Birth :	mm/dd/yyyy
Age :
Gender :
Work Phone :
Fax :
Email :
Earliest date you can start :	mm/dd/yyyy
Latest date you can start :	mm/dd/yyyy
Your Nationality :
Your Language :
What other languages do you speak ?
Have you ever lived away from your family and friends for 2 month or more ?	Yes No
Have you traveled outside your home country for 2 weeks or more ?	Yes No
Medical-Certificate : Yes No Medical Certificate You must have a clean bill of health. Please click this link to get a printable medical certificate form.
Do you have allergies to animals or food ?	Yes No
Drivers License :
Smoking :	Yes No
What religion do you practice ?
Worked as aupair before? Please give Names, Address, Telephone number, Email address and recent References (no Relatives) : (Not more than 300 characters)
Dear Family letter :
Children's ages you are comfortable with taking care of :
Willing to work with handicapped children :	Yes No
Can you swim ?	Yes No
Do you hold a First Aid certificate ?	Yes No
Do you have Nurses-Training ?	Yes No
Did you attend Newborn-Classes ?	Yes No
Can you Cook ?	Yes No
Will you do light household duties ?	Yes No
Will you do Ironing ?	Yes No
Are you traveling as a single person ?	Yes No
Are you seeking a live-in or live-out situation ?	Yes No
Remuneration: 30 hours = $150, 35 hours = $180, 40 hours = $200 per week paid directly to candidate. You will not be offered a position with children under 2 years unless you can produce qualifications and references pertaining to the care of this age group. If a position is offered assisting mother in the home with under 2's the decision will be left up to her regarding your duties.
Education and Qualifications :
What are your Hobbies and Interests ?
Medical Insurance, Travel Arrangements are YOUR responsibility. Do you understand ?	Yes No