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Hosting Family Application Form

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Hosting Family Application Form Powered By Docstoc
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Au Pair Application form
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First name
Family name
Country requested?
Earliest departure date?                                        Latest departure date?
How long can you stay?
Do you prefer a family      O a town         (if there are no   O suburbs                      O country
in:                         families-available in the city
                            centre, you’re supposed to be
                            placed in the suburbs)
Complete address
Telephone N° (with code)                                        Mobile N°(with code)
E-mail
Date of birth                                                   Place
Age                                                             Nationality
Marital status
Cod. Fisc.
Height                                                          Weight

Previous and/or current occupations
Have you completed 12 years of schooling?                       O Yes            O No
Studies Performed
Do you have any future plans for further
education?
Parents’ occupation


Brothers and sisters   (name and age)




                                                                                                           1
                                   Via dei Platani, 100 – 20020 Arese – Milano – Italia
                                     Fax: +390293580439 – Tel: +393497946488
                       www.internationalaupairitaly.com – E-mail: info@internationalaupairitaly.com
Please circle, underline, highlight or bold the words that best describe characteristics of your
personality and lifestyle and then list below any other of your dominant qualities.
neat          attentive     messy                     honest         clean
negative      organised nature lover                  sensitive      creative
mature        caring        hard working              witty          responsible
artistic      calm          shy                       mature         dependable
loud          positive      openmind                  athletic       indipendent


Do you presently have a serious boyfriend or                   O Yes               O No
girlfriend?
Explain how you will cope with homesickness
when away from your boyfriend/girlfriend for
up
to 12 months?

Foreign languages:
English              O Fluent            O Good                 O Fair                O Little            O None
French               O Fluent            O Good                 O Fair                O Little            O None
Spanish              O Fluent            O Good                 O Fair                O Little            O None
German               O Fluent            O Good                 O Fair                O Little            O None
Italian              O Fluent            O Good                 O Fair                O Little            O None
Other (languages and level)
Have you ever been abroad before?
O Yes           O No
If Yes, in which countries?
Have you ever lived on your own?                                O Yes O No        If yes, for how long?

Do you wish to attend a language course, when O Yes                                O No
abroad?


Do you smoke?                                                   O Yes        O No
If yes, how many cigarettes per day?
Would you accept to smoke only outside the O Yes                             O No
house?




                                                                                                                   2
                                     Via dei Platani, 100 – 20020 Arese – Milano – Italia
                                       Fax: +390293580439 – Tel: +393497946488
                         www.internationalaupairitaly.com – E-mail: info@internationalaupairitaly.com
Do you hold a driving licence?                                O Yes         O No        If yes, for how long?

Are you willing to drive abroad?                              O Yes              O No                  O Occasionally
If yes , date passed of the driving licence:                  Automatic:            O Yes              O No
                                                              Manual:             O Yes                O No
Have you ever had an accident:                                O Yes O No
How often you drive:
What conditions do you have experience to drive in? Please circle which applies:
City                        Hightway                          Rural                               Snow
Night                       Wet                               Right hand drive                    Left hand drive
Do you have special diet, allergies etc…?                     O Yes O No        If yes, specify

Do you have any dietary restrictions?                         O Yes O No        If yes, give details



Are you vegetarian?                                           O Yes O No
If yes, please indicate if you are prepared to O Yes O No
live with a family who is not, and if you are
prepared to handle meat.


Do you drink alcohol?                                         How often?_
Do you like animals?                                          O Yes O No O It depends                  Please, specify



Have you ever been an au pair before?                         O Yes              O No
If yes, in which country and for how long?
Would you like to be placed as:                               O Au Pair          O Mother’s help                O Don’t mind
How much experience do you have with:
looking after children aged 0-2                               Good                   Some                       None
looking after children aged 3-7                               Good                   Some                       None
looking after children aged 8-12                              Good                   Some                       None
looking after disabled children                               Good                   Some                       None
keeping children occupied (play with them)                    Good                   Some                       None
doing light housework                                         Good                   Some                       None
washing/ironing clothes                                       Good                   Some                       None
                                                                                                                           3
                                   Via dei Platani, 100 – 20020 Arese – Milano – Italia
                                     Fax: +390293580439 – Tel: +393497946488
                       www.internationalaupairitaly.com – E-mail: info@internationalaupairitaly.com
cooking simple meals                                         Good                   Some                        None
looking after pets                                           Good                   Some                        None




Which ages of children do you like best?
                                                            O Don't mind
Are you ready to take care of disabled children? O Yes                    O No        O It depends
Would you accept a single parent family?                    O Mother          O Father          O Either          O Neither
Would you accept a family with a different O Yes                          O No        O It depends
religion?
Your hobbies or interests:


Can you swim?                                               O Yes               O No
Do you like sports?                                         O Yes               O No
If yes, which ones?
Have you ever been charged or convicted of a O Yes                              O No
criminal offence?                                           If yes, specify




Have you been hospitalised or under the care O Yes                              O No      if yes, give details:

of a doctor within the last 12 months?
Do you have any chronic or recurring health O Yes                               O No      if yes, give details:

problems eg asthma, diabetes, cold sores?
Would you agree to undergoing a test for O Yes                                  O No
aids/HIV?
Do you have any allergies(include pets)?                    O Yes               O No    if yes, give details:




                                                                                                                              4
                                  Via dei Platani, 100 – 20020 Arese – Milano – Italia
                                    Fax: +390293580439 – Tel: +393497946488
                      www.internationalaupairitaly.com – E-mail: info@internationalaupairitaly.com
Please, rate your top five reasons for wanting to be an au pair/nanny,with ONE being the most
important reason, and FIVE being the least important reason:
1)
2)
3)
4)
5)
Special wishes and/or important remarks for your placement:




I (name in full)_____________________________confirm that all the information supplied
on this form is true and correct.

     Date ____________________Signature ________________________________________




                                                                                                   5
                                Via dei Platani, 100 – 20020 Arese – Milano – Italia
                                  Fax: +390293580439 – Tel: +393497946488
                    www.internationalaupairitaly.com – E-mail: info@internationalaupairitaly.com
1 AU PAIR REFERENCE
Applicant’s name:                                                 Your name:


Your address:                                                     Your Phone
                                                                  number:

How long have you                                                 What is Your
known the applicant?                                              relationship to
                                                                  the applicant?

How long the applicant                                            How long the applicant
helped you with your                                              helped you with your
children?                                                         children?

How many times                                                    How many children did
did the applicant                                                 the applicant look
take care of your                                                 after?
children?

How old were                                                      Please describe the
they?                                                             applicant’s duties?

Did the applicant help                                            If yes what was
with housework?                  YES        NO                    his/her duties?


Please indicate your opinion about the level of the applicant’s abilities in each of the following categories.

Please put a tick   V in the relevant level boxes below which you think is acceptable.
SKILLS                     Excellent           Good               Fair                   Poor                 Not
Applicable
Responsibility
Friendliness
Honesty
Maturity
Ability to discipline
children
Flexibility
Helpfulness
Punctuality
Cleaning
Tidying
Ironing
Basic cooking


Do you recommend the applicant to be placed as an au pair?
………………………………………………………………………………………………………………………………………………………………………………………

I hereby confirm that all the information above is correct.


Name / Surname:                                  Signature                                                 Date:
……………………………………………….                              ……………………………                                               …….. /…… / …….

                                                                                                                            6
                                        Via dei Platani, 100 – 20020 Arese – Milano – Italia
                                          Fax: +390293580439 – Tel: +393497946488
                            www.internationalaupairitaly.com – E-mail: info@internationalaupairitaly.com
2 AU PAIR REFERENCE
Applicant’s name:                                                 Your name:


Your address:                                                     Your Phone
                                                                  number:

How long have you                                                 What is Your
known the applicant?                                              relationship to
                                                                  the applicant?

How long the applicant                                            How long the applicant
helped you with your                                              helped you with your
children?                                                         children?

How many times                                                    How many children did
did the applicant                                                 the applicant look
take care of your                                                 after?
children?

How old were                                                      Please describe the
they?                                                             applicant’s duties?

Did the applicant help                                            If yes what was
with housework?                  YES        NO                    his/her duties?


Please indicate your opinion about the level of the applicant’s abilities in each of the following categories.

Please put a tick   V in the relevant level boxes below which you think is acceptable.
SKILLS                     Excellent           Good               Fair                   Poor                 Not
Applicable
Responsibility
Friendliness
Honesty
Maturity
Ability to discipline
children
Flexibility
Helpfulness
Punctuality
Cleaning
Tidying
Ironing
Basic cooking


Do you recommend the applicant to be placed as an au pair?
………………………………………………………………………………………………………………………………………………………………………………………

I hereby confirm that all the information above is correct.


Name / Surname:                                  Signature                                                 Date:
……………………………………………….                              ……………………………                                               …….. /…… / …….
                                                                                                                            7
                                        Via dei Platani, 100 – 20020 Arese – Milano – Italia
                                          Fax: +390293580439 – Tel: +393497946488
                            www.internationalaupairitaly.com – E-mail: info@internationalaupairitaly.com
AU PAIR MEDICAL CERTIFICATE
APPLICANT’S INFORMATION
Full Name:                                                 Date of Birth:
Gender                    Male Female                      Blood Type:

PHYSICIAN’S INFORMATION
Name of the Doctor                                         Telephone:
and/or Clinic:

Address:


HAS THE APPLICANT EVER HAD (OR CURRENTLY HAS):
Asthma                  Yes No                 Dizziness              Yes No
Anorexia                Yes No                 Headaches              Yes No
Chicken Pox             Yes No                 Allergies              Yes No
Heart Disease           Yes No                 Emotional Disorders Yes No
Measles                 Yes No                 Tuberculosis           Yes No
Epilepsy                Yes No                 Anaemia                Yes No
Hepatitis               Yes No                 Arthritis              Yes No
Seizures                Yes No                 Bulimia                Yes No
Diabetes                Yes No                 Depression             Yes No
Mumps                   Yes No                 German Measles         Yes No
Malaria                 Yes No                 Other                  Yes No
If the answer is “Yes” to any of the above questions, please give details and dates.



Has the applicant undergone surgery of any kind?
Please give details.

Has the applicant ever received treatment for psychological
problems?
If yes, please give detail:


Is the applicant restricted physically and/or mentally?
If yes, please give detail:


I certify that the above information is complete and accurate and all important medical
information has been included.

Doctor’s Stamp:                                             Doctor’s Signature                      Date:



                                                                                                            8
                                 Via dei Platani, 100 – 20020 Arese – Milano – Italia
                                   Fax: +390293580439 – Tel: +393497946488
                     www.internationalaupairitaly.com – E-mail: info@internationalaupairitaly.com
                                          AU PAIR AGREEMENT
      I(fullname)______________________________________________________________
 1. confirm that I have read all written materials provided by the au pair agency in my
       home country and my host country and that I fulfil all criteria. I understand that
       the au pair program is a cultural exchange program and not a contract of work. I
       am aware that being an au pair requires a high degree of both responsibility and
       flexibility and that I must take my duties seriously.
2.     I confirm that I have answered all questions honestly and that all information in the
       application is true.
3.     After confirmation of placement, I shall stay in touch with my host family and shall
       inform them of my travel arrangements. I agree not to travel to my host family
       until I have received an official confirmation of placement from the au pair agency.
4.     I shall be familiar myself with all (if any) visa requirements. I shall obtain necessary
       documents (e.g., a valid passport) prior to departure and shall not enter my host
       country without a proper visa (if required).
5.     I agree to cover all costs for language courses, travel to and from my host country
       and any debts incurred (e.g., telephone bills, etc.). I shall bring emergency funds
       with me (as recommended by the au pair agency) to pay for unforeseen expenses.
6.     I am familiar with and agree to abide by all program guidelines and conditions, in
       particular those regarding: the number and distribution of working hours, au pair
       duties, pocket money, free time, holidays, language courses, transportation costs,
       insurance and the termination of an au pair arrangement.
7.     Upon arrival in my host country, I shall discuss in detail with my host family the
       daily or weekly routine and my and their expectations of the au pair programme.
8.     I shall carry out my child care and light housekeeping duties with diligence. In
       addition to my au pair duties, I agree to keep my room clean and neat and to make
       a fair contribution to the cleanliness of the "common areas" of my host family's
       home.
9.     I agree to abide by all house rules set by the host family (e.g., use of telephone
       and facilities within the home, daytime and overnight visitors, curfew, smoking,
       etc.). During my stay I shall behave in a manner which does not reflect badly upon
       my host family, both au pair agencies or my home country.
10.   I shall seek the advice of the host family before administering any form of discipline
       on the children. Under no circumstances shall I hit the children or leave them
       alone.
11.     I shall discuss with my host family any arrangements for holidays well in advance.
12.    I shall make a concerted effort to experience the culture of my host country and to
       learn the language. I shall respect cultural differences and display tolerance
       towards others.
13.    I realize that the success of my au pair stay depends largely on my own initiative. I
       shall try to integrate myself into family life and, should any problems arise,
       communicate openly with the family and actively seek a solution.

                                                                                                    9
                                 Via dei Platani, 100 – 20020 Arese – Milano – Italia
                                   Fax: +390293580439 – Tel: +393497946488
                     www.internationalaupairitaly.com – E-mail: info@internationalaupairitaly.com
14. If I have any problems or questions which cannot be discussed and resolved with
    the host family, I shall contact the au pair agency in my host country for
    assistance.
15. I shall make every effort to resolve any differences with my host family. If no
    solution can be reached and I decide to leave the family, I agree to give advanced
    notice of minimal 2 weeks. During this time period, I shall perform my normal
    duties and receive room, board and pocket money. If I request to be placed with a
    new family, I realise this might involve moving to a different city.

16. I understand that I shall be expelled from the program and must return home if:

     - I fail to abide by this agreement or program guidelines.
     - I falsify any information in my application (e.g., regarding smoking, child care
       experience, health, etc.).
     - I begin my au pair stay before receiving an official confirmation of placement
       from the au pair agency or a proper visa, if required.
     - I am responsible for repeated problems with several families.
     - I disobey the laws of my host country.

17. I agree to leave my host country before my visa or residency permit expires (if
    applicable) and I will notify the police and the au pair agency of my departure.

18. I shall not undertake any other paid employment and will perform only those tasks
    related to the au pair program.

19. Should I decide to cancel my application, I shall inform the au pair agency at once.

20. I shall notify the au pair agency immediately if there are any changes to the
    information included in my application.



Date ____________________                  Signature ________________________________________




                                                                                                  10
                               Via dei Platani, 100 – 20020 Arese – Milano – Italia
                                 Fax: +390293580439 – Tel: +393497946488
                   www.internationalaupairitaly.com – E-mail: info@internationalaupairitaly.com

				
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