Register as an Au Pair
Surname
First name
Gender
Please Select
Male
Female
Not given
Marital status
Please Select
Married
Single
Divorced
Co-habiting
Nationality
Religion
Age
Do you live with your parents?
Yes
No
Date and place of birth
Do you have a steady partner?
Yes
No
Do you have any children?
Yes
No
Father's occupation
Mother's occupation
Ages of Brothers (if any)
Ages of Sisters (if any)
Present occupation
When can you leave?
How long for?
Where would you like to go? (Country/Region)
Have you any friends or relatives in the country you propose to visit?
Any Area you would prefer to work in
Most positions include light housework. Is there any work you would refuse to do?
Can you cook?
Yes
No
Can you sew?
Yes
No
Can you swim?
Yes
No
Do you drive?
Yes
No
Licence date
Would you object to a family of a different religion?
Yes
No
Would you object to a single parent family?
Yes
No
Would you object to an ethnic family?
Yes
No
Please give details of any health problems or physical disabilities
Please give details of any allergies
Do you require a special diet? If so, please give details
What is your height?
Weight
Hair colour
Eye colour
Do you have any childcare experience?
Do you have any childcare qualifications?
Have you any First Aid qualifications?
Which languages do you speak (State Level)
Age of children preferred
Do you wish to attend language classes?
Yes
No
Would you describe yourself as:
Cheerful
Reliable
Caring
Flexible
Quiet
Talkative
Sensitive
Good sense of humour
Outgoing
Sporty
Puctual
Do you smoke?
Yes
No
If you smoke, would you agree not to smoke in the house?
Yes
No
What are your interests and hobbies?
Which sports do you like?
Do you like animals?
Yes
No
Are you allergic to animals?
Do you have any criminal convictions?
Yes
No
If yes, please state
Do you possess a Police Clearance Certificate?
Yes
No
Passport number
Expiry date
Home Address including postcode
Email address
Daytime Telephone Number
Evening Telephone Number
Mobile Telephone Number
Next of Kin Name & Address including postcode
Agreement to Agency Terms
Declaration: I declare that the information I have given is true to the best of my knowledge. I accept liability for any problem or difficulty that I may experience as a result of any false information.
Declaration:
*
Accept
Full name
*
Date
*
Send
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