Family Details
Surname
Name
Address
Telephone (Daytime)
Telephone (Evening)
E-Mail
Fax
Occupation
Husband
Wife
Nationality
Husband
Wife
Religion
Husband
Wife
Do you have any child under 16 ?
YES
NO
Number of children
1
2
3
4
5
6
Name of Child
Sex of Child
Age of Child
Allergic
Child 1 :
----
Male
Female
----
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
NO
YES
Child 2 :
----
Male
Female
----
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
NO
YES
Child 3 :
----
Male
Female
----
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
NO
YES
Child 4 :
----
Male
Female
----
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
NO
YES
Child 5 :
----
Male
Female
----
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
NO
YES
Child 6 :
----
Male
Female
----
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
NO
YES
Is a new baby expected?
YES
NO
Is your home in
(Location)
City
Town
Village
Countryside
Will the au pairs room be heated?
YES
NO
Will the au pairs bedroom be own?
YES
NO
Will the au pairs bathroom be own?
YES
NO
Will the au pairs have private TV?
YES
NO
Will the au pairs be able to use PC & Internet?
----
PC Only (Private)
PC & Internet (Private)
PC Only (Common)
PC & Internet (Common)
Neither
Are there family pets in the house?
YES
NO
What are they?
Is the au pair expected to help with the care of animals?
YES
NO
Does the family have special diet?
YES
NO
What is the main language spoken at home?
Is driver licence essential?
YES
NO
Is a car provided for the au pairs personal use?
YES
NO
Does any member of the house smoke?
YES
NO
Will you accept a smoker?
YES
NO
What free time will the au pair be allowed?
(Normally 2 full days per week)
How many hours will the au pair work per week?
Please fill in the duties you require the au pair to do for each day they will work.
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Pocket many paid weekly
(min£45)
(upto 25 hours + two nights babysitting is au pair. Over 25 hours per week is au pair plus)
Au Pairs can receive extra pay for extra hours.
The au pair should be given adequate time to attend language courses and cultural activities.
Please advise costs and location of English lessons.
Please list what additional specifications that you want the au pair should have
.
How did you hear about us?
----
Search Engines(Google,Yahoo,Altavista...)
Television
Magazine
Newspaper
Friend(s)
Other
Have we supplied you with an au pair previously?
YES
NO
* All answers are required.
Thank you for your patient.
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