Address:
Postcode or Zipcode:
Telephone Day:
Telephone Eve:
Mobile:
E-Mail:
Mothers Details:
Name:
Nationality:
Profession:
Religion:
Father Details:
Name:
Nationality:
Profession:
Religion:
Children:
Name Gender Sex
1:
M
F
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
2:
M
F
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
3:
M
F
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
4:
M
F
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
Are you
expecting a new baby?
Yes No
PROPERTY:
Type
of Property:
No.
of Bedrooms:
No.
of Bathrooms:
CONSIDERATIONS:
Details
of Pets:
Other
Domestic Help:
Do
you smoke?
Yes
No
Special
Dietary Requirements:
Please give
details of any allergies, health problems, or special dietary requirements - eg vegetarian
Facilities
in the locality:
Distance
to nearest bus stop:
Distance
to nearest train station:
Nearest
English School:
Cost
of School per term:
Pocket
Money offered per week:
Will the Au Pair
have own bedroom?
Yes
No
Will the Au Pair
have own bathroom?
Yes
No
Yes
No
Au Pair have use
of phone?
Daily
Weekly
In Own Time
Not At All
Au Pair allowed
friends over?
Daily
Weekly
In Own Time
Not At All
Au Pair allowed
friends to stay?
Daily
Weekly
In Own Time
Not At All
Please give
details of any restrictions you require the Au Pair to observe within your home:
DUTIES:
Weekly rota. Detail hours you
require Au Pair to be available
Monday:
Tuesday:
Wednesday:
Thursday:
Friday:
Saturday:
Sunday:
No. of
Evenings required to baby-sit:
0
1
2
3
4
5
6
7
Will the Au Pair
be required to take sole charge of the children during the day?:
Yes
No
Please describe
the childcare duties you expect the Au Pair to undertake eg dressing, washing, preparing meals, organising play, reading stories,
bathing, putting to bed.
Have you
had an Au Pair before?
Yes
No
Date
you would like Au Pair to arrive:
3 Months
4-6 Month
7-12 Months
1+ Years
Duties you expect
the Au Pair to undertake. Eg dusting, hoovering, laying the table, tidying up, using
dishwasher, washing machine, simple cooking for children ironing etc
Would you consider a male Au Pair?
Yes
No
Is a Non-smoker:
Essential
Preferable
Not necessary
Is a car driver:
Essential
Preferable
Not necessary
Preferred Nationality:
W. Europe
Central/E Europe
Turkish
Any
Is spoken English
on arrival:
Essential
Preferable
Not necessary
Additional Comments: