Opening Doors to the World since 1980!

hCULTURAL HOMESTAY INTERNATIONALh

------NON-PROFIT EDUCATIONAL EXCHANGE PROGRAM------
104, BUTTERFIELD ROAD, SAN ANSELMO, CA 94960
Tel. 1 (415) 459-5397 Fax. 1 (415) 459-5603
www.chiaupairusa.org

Au Pair Name:
Reference Name:
Verified By:
Date:
CHILD CARE VERIFICATION

1) Did the candidate provide childcare for you?

2) If yes, did the applicant live with your family and provide live in childcare?

3) How old were the children that the candidate provided childcare for when he/she began taking
care of them?

4) How old were the children that the candidate provided childcare for when he/she ended taking
care of them?

5) Did the applicant take care of more than one child at once?

6) If yes, how many children did the applicant take care of at once?

7) Was the applicant ever the only responsible person taking care of the children ( was he/she every
alone with the children?)

8) How often did the applicant provide childcare for you?

9) For how long (how many hours) each day did the applicant provide childcare?

10) Please list the top five duties the applicant completed with the children.

11) Did the applicant complete these duties alone or with help?

12) Was the applicant every responsible for driving the children?

INFANT CARE

13) Did the candidate ever take care of an infant ( child under the age of two years old)?

14) If yes, how old was the infant when the applicant began taking care of him/her?

15) How old was the infant when the applicant finished taking care of him/her?

16) Was the applicant ever left alone with the baby so he/she was the only one responsible for taking
care of the baby?

17) Please list the five main duties the applicant had to complete with the baby.

18) Did the applicant complete these duties alone or with help?

19) Is the applicant comfortable changing diapers by herself?

20) Does the applicant know how to feed infants?


- When you call to verify childcare references, please complete the form above and submit
this with the application -