Confidential Host Family Reference Form
A Personal Reference must be submitted by host families as a part of the application process for hosting an au pair from abroad. The Character Reference is CONFIDENTIAL and the information contained herein will be kept in confidence.
Directions: Please fill out this form and fax it, mail it, or scan it and send to the following contact information.
Fax: 415-373-3741 Address: Agent Au Pair, 1450 Sutter St., #526 San Francisco, CA 94109 Email: placement@agentaupair.com
Personal Reference
Name of Applicant (s) _____________________________________________________ Name of Reference _______________________________________________________ Location________________________________________________________________ Telephone ______________________________________________________________ When is the best time to phone? _____________________________________________ How long have you known the applicant(s)?____________________________________ Describe your relationship with the applicant(s) _________________________________ How would you describe the relationship between the applicants? __________________ How would you describe the relationship among all family members? _______________ ________________________________________________________________________ Please describe the general cleanliness, neatness and maintenance of how the applicant(s) keep the home ___________________________________________________________ To your knowledge, has there ever been any history or violence or abuse in the home (if yes, describe)____________________________________________________________ Are you aware of any drug or alcohol abuse in the home? ________________________ To your knowledge, has anyone in the home ever been convicted of a felony (if yes, please describe details) ________________________________________________________________________ ________________________________________________________________________
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How would you describe the physical and mental health of the applicant(s) and all family members? _______________________________________________________________ If it was your daughter or son, would you feel totally comfortable having him/her live in the family home for a year (if no, explain) _____________________________________ ________________________________________________________________________ Please put a check on the line which best describes your opinion of the family with regard to the following: Excellent Good Poor Don’t know Financial Stability Communication ________ ________ _______ _______ _______ _______ _______ _______ _______ _______ _______
Honest and Genuine ________ Acceptance of Foreigners Moral Character Physical Health Mental Health Happiness
________ ________ ________ ________ ________
_______ _______ _______ _______ _______
_______ _______ _______ _______ _______
_______ _______ _______ _______ _______
If you rated “poor” to any of the above, please explain your reasons ________________________________________________________________________ Do you feel that the applicant(s) is (are) good candidate(s) for participating in a foreign exchange program? ________________________________________________________________________ Do you have any other general comments about the applicant(s) you would like to add? ________________________________________________________________________
I certify that the above information is true and correct to the best of my knowledge.
____________________________________ Signature
_____________________ Date
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