inscription uk

Inscriptions :

YOUR STAY

First date available to start work : Last date available :

Host country : Length of stay required :

Type of stay : Au Pair Summer Au Pair

PERSONAL DETAILS

Surname : First name :

Address :

Post code : City :

Country :

Tel. nr home : Office :

Portable : Fax nr :

Email :

Date of birth : Place of birth :

Nationality :

Passport Nr :
(only if visa required) Date of issue :
(only if visa required)

Passport Date :
(only if visa required) Passport place :
(only if visa required)

Religion : Practising : Yes No

Height : Weight :

Gender : Male Female

Are you willing to live in a family with animals ? Yes No No difference

Have you ever lived away from home more than 2 months ? Yes No

Give details :



HEALTH

Are you healthy ? Yes No

If no, please explain
(asthma, diabetes, other...) :

Are you allergic to animals ? Yes No Dont know

Other serious allergies ?

Do you have a special diet ?
(eg. Vegetarian) If yes, explain

Do you smoke ? Yes No                How many cigarette / day :

If you do smoke are you willing to refrain smoking in the host family's house or in the presence of the children ? Yes No



DRIVING

Do you hold a current driving licence ? Yes No

When did you receive the licence ?

Good experience ? Yes No

Are you willing to drive in the host country ? Yes No

YOUR FAMILY

Parent's address :

Parent's tel.nr :

Father's occupation :

Mother's occupation :

Family's members
(brothers, sisters and ages) :

Contact person in case of emergency : (if other than parents)

EDUCATION

Last year of school : Date :

Diploma(s) :

Future educational plan ?

Do you have knowledge of first aid or life saving ? Yes No

HOBBIES AND INTERESTS

What are your special hobbies / interests?

Do you participate in sports ? Yes No

which ones :

Do you swim ? Yes No

Do you have a background in music and dance ? Yes No

EMPLOYMENT RECORD

Employments
          Dates

EXPERIENCE WITH CHILDREN

Do you have experiences with : newborns three months old children aged 9-12 months
1 to 3 years 3 to 6 years 6 to 10 years older than 10 years
None

How often (frequency) ?

Have you taken any course relating to child care ? Yes No

Have you ever been an au pair before ? Yes No

If so, in which country and for how long ?

EXPERIENCE WITH HOUSEWORK

What experience of light housework do you have ?

LANGUAGES SKILLS

Mother tongue :

First language : Verbal skills : Poor Fair Good Fluent

Second language : Verbal skills : Poor Fair Good Fluent

Language of host country :

Number of years studied :

Certificates held ?

Which educational courses do you wish to attend in your host country ?

REASONS FOR APPLYING

Why do you want to be an au pair ?

Why do you want to travel abroad ?

PREFERENCES

Would you prefer a family with : 1 2 3 4 children

Ages :

Would you prefer to live... in a big city in a small town in a suburb in a rural area

Are you willing to work with a single parent family ? Yes No

Are you willing to work in families of all religious background ? Yes No

Your comments :

I certify that this information is true.

Date : *

Signature : *



JEUNESSE ET NATIONS AU PAIR
49, rue du Lt Cl de Montbrison - 92500 Rueil-Malmaison - France
Tel/fax : 33 - 01 41 42 16 19

Horaires : 9 h 30 - 12 h 30 / 13 h 30 - 17 h 30
lundi au vendredi - Accueil sur rendez-vous

* Champs obligatoires

YOUR STAY
First date available to start work :		Last date available :
Host country :		Length of stay required :
Type of stay :	Au Pair Summer Au Pair

PERSONAL DETAILS
Surname :		First name :
Address :
Post code :		City :
Country :
Tel. nr home :		Office :
Portable :		Fax nr :
Email :
Date of birth :		Place of birth :
Nationality :
Passport Nr : (only if visa required)		Date of issue : (only if visa required)
Passport Date : (only if visa required)		Passport place : (only if visa required)
Religion :		Practising : Yes No
Height :		Weight :
Gender :	Male Female
Are you willing to live in a family with animals ?	Yes No No difference
Have you ever lived away from home more than 2 months ?	Yes No
Give details :

HEALTH
Are you healthy ?	Yes No
If no, please explain (asthma, diabetes, other...) :
Are you allergic to animals ?	Yes No Dont know
Other serious allergies ?
Do you have a special diet ? (eg. Vegetarian) If yes, explain
Do you smoke ?	Yes No How many cigarette / day :
If you do smoke are you willing to refrain smoking in the host family's house or in the presence of the children ?	Yes No

DRIVING
Do you hold a current driving licence ?	Yes No
When did you receive the licence ?
Good experience ?	Yes No
Are you willing to drive in the host country ?	Yes No

YOUR FAMILY
Parent's address :
Parent's tel.nr :
Father's occupation :
Mother's occupation :
Family's members (brothers, sisters and ages) :
Contact person in case of emergency :	(if other than parents)

EDUCATION
Last year of school :		Date :
Diploma(s) :
Future educational plan ?
Do you have knowledge of first aid or life saving ?	Yes No

HOBBIES AND INTERESTS
What are your special hobbies / interests?
Do you participate in sports ?	Yes No
which ones :
Do you swim ?	Yes No
Do you have a background in music and dance ?	Yes No

EMPLOYMENT RECORD
	Employments	Dates




EXPERIENCE WITH CHILDREN
Do you have experiences with :	newborns three months old children aged 9-12 months 1 to 3 years 3 to 6 years 6 to 10 years older than 10 years None
How often (frequency) ?
Have you taken any course relating to child care ?	Yes No
Have you ever been an au pair before ?	Yes No
If so, in which country and for how long ?

EXPERIENCE WITH HOUSEWORK
What experience of light housework do you have ?

LANGUAGES SKILLS
Mother tongue :
First language :		Verbal skills : Poor Fair Good Fluent
Second language :		Verbal skills : Poor Fair Good Fluent
Language of host country :
Number of years studied :
Certificates held ?
Which educational courses do you wish to attend in your host country ?

REASONS FOR APPLYING
Why do you want to be an au pair ?
Why do you want to travel abroad ?

PREFERENCES
Would you prefer a family with :	1 2 3 4 children
Ages :
Would you prefer to live...	in a big city in a small town in a suburb in a rural area
Are you willing to work with a single parent family ?	Yes No
Are you willing to work in families of all religious background ?	Yes No
Your comments :

I certify that this information is true.
Date :	*
Signature :	*



JEUNESSE ET NATIONS AU PAIR 49, rue du Lt Cl de Montbrison - 92500 Rueil-Malmaison - France Tel/fax : 33 - 01 41 42 16 19 Horaires : 9 h 30 - 12 h 30 / 13 h 30 - 17 h 30 lundi au vendredi - Accueil sur rendez-vous * Champs obligatoires