Living aupair USA form

Children from 0 – 24 months old

Children from 3 – 6 years

Children from 7 – 12 years

Which age groups would you prefer?

0 - 1 year1 - 2 years2 - 3 years3 - 6 years6 - 12 yearsolder
Do you have any experiences with a disabled child?

yesno
Would you take care of a disabled child?

yesno
Describe your experiences in taking care of children
Which duties of housework are you familiar with?

cleanin upironingdoing loundryvacuumingdoing dishescoockingpreparing snakstalking care plantsother
Education and skills
Which graduation/profession do you have?
Current employment situation
Work experiences (also stage)
Your interests (hobbies)?
Do you have additional abilities, like first-aid course, ect?
Do you have a driving licence?

yesno
if no, will you get a driving licence before the arrival date?

yesno
If yes, how often do you drive?
What conditions do you have experience to drive in?

cityruralsnownightrigh hand driveleft hand drive

further information

	yes	no
Would you be prepared to drive the host family’s car?
Do you play a musical instrument?
Are you able to swim?
Do you drink alcohol?
Do you like animals?
Would you take care of pets?
Do you have special diet, allergies ect?

	yes	no
Do you have any dietary restrictions?
Are you vegetarian?
If yes, would you be prepared to cook meat?
Do you smoke?

if you smoke,

	yes	no
Would you smoke outside?
Would you stop smoking, if the family wants you to?

Your family
Mother (name, surname, profession)
Father (name, surname, profession)
Brothers/Sisters (name, age)
Final information
Why did you choose the au pair program? (Please, rate your reasons for waiting to be an au pair)
Have you ever been to USA before?

yesno
Do you have any contact person in this country?

yesno
If yes, please fill your contact person's details

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
Please upload a photo of yourself smiling

Upload a File

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place
Date

MonthDayYear
I declare that all of the data given is correct and true.

yes
Signature

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Application form for USA placement