Au Pair Application PDF

Au Pair Application Packet
Applicant Name: ____________________________________________________________________________________________

Applicant Email: _____________________________________________________________________________________________
Applicant Skype: ____________________________________________________________________________________________
DOB and Current Age: _______________________________________________________________________________________
Infant Qualified? ____________________________________________________________________________________________
Driver? ____________________________________________________________________________________________________
First Available Date: _________________________________________________________________________________________
Last Available Date: _________________________________________________________________________________________
Au Pair Foundation Internal Use Only
I.D. Number: _______________________________________________________________________________________________

Au Pair Program Preference: __________________________________________________________________________________
Application Received Date: ___________________________________________________________________________________
Reviewed By: ______________________________________________________________________________________________
Approved By: _______________________________________________________________________________________________
Notes: _____________________________________________________________________________________________________
Date Added to Public Website: _________________________________________________________________________________
Date Added to RD Website: ___________________________________________________________________________________
1 (17)
APF GLOBAL EXCHANGE, NFP
APF July 2013
205 Keller Street, Suite 204

Petaluma, CA 94952, USA
www.aupairfoundation.org
Phone: +1 866-428-7247
Fax: +1 707-658-2393
info@aupairfoundation.org
Au Pair Application
Applicant Information
Family Name: __________________________________________ First Name: __________________________________________

Middle Name: _________________________________________ Suffix: _______________________________________________
Gender:
Male
Female
Date of Birth (mm/dd/yyyy):_____________________________
City of Birth: ___________________________________________ Country of Birth: ______________________________________

Country of Citizenship: _______________________________________________________________________________________
Country of Legal Permanent Residence: _________________________________________________________________________
Email: _____________________________________________________________________________________________________
Skype: ____________________________________________________________________________________________________
Mailing Address: ____________________________________________________________________________________________
City: __________________________________________________ Postal Code: _________________________________________
Passport Number: ___________________________________________________________________________________________
Passport Expiration: _________________________________________________________________________________________
Do you have a Drivers License?
Yes
No
If yes, when did you receive it? _________________________________________________________________________________
2 (17)
APF July 2013

Phone: +1 866-428-7247
Fax: +1 707-658-2393
Au Pair Application
Applicant Information
What is the date range that you are available to enter the U.S. to start the Au Pair Program?
First Date (MM/DD/YYYY): ___________________________________________________________________________________
Last Date (MM/DD/YYYY): ___________________________________________________________________________________
Nearest International Airport: __________________________________________________________________________________
Time zone: _________________________________________________________________________________________________
Best time in your home country to call: __________________________________________________________________________
Telephone: (country code) _______________________________ City Code: ___________________________________________
Home Number: _____________________________________________________________________________________________
Work Number: _____________________________________________________________________________________________
Cell phone: _________________________________________________________________________________________________
Highest Level of Education Attained: ___________________________________________________________________________
Other Education and Professional Training: ______________________________________________________________________
Languages Spoken: __________________________________________________________________________________________
Current Profession: __________________________________________________________________________________________
Emergency Contact Information

Emergency Contact Name: ____________________________________________________________________________________
Relationship to Au Pair: _______________________________________________________________________________________
Address: ___________________________________________________________________________________________________
City: ________________________________ State: _____________________________ Country: ___________________________
Primary Phone: _____________________________________________________________________________________________
Secondary Phone: ___________________________________________________________________________________________
3 (17)
APF July 2013

Phone: +1 866-428-7247
Fax: +1 707-658-2393
Au Pair Application
Childcare Experience
Note: All Au Pairs must have at least 200 hours of childcare experience. The US Government requires that Au Pairs looking after
infants under the age of two must have at least 200 hours of childcare experience with infants under the age of two, excluding
experience with the Au Pairs own family or relatives. Many of our Host Families have children under the age of two. Please provide
documentation of your childcare and infant care experience to enable you to be placed as an Infant Care Au Pair with one of
these families.
Childcare Experience with Age Groups (Check appropriate groups)

324 months
510 years
25 years
Over 10 years
Other
I have 200 hours of documented Infant Care Experience:

(If Yes, be sure to document below.)
Yes
No
Do you have experience with children with special needs?
Yes
No
Describe any special needs experience: __________________________________________________________________________
Childcare Experience 1 (Please list youngest childcare experience first)

Ages and names of child(ren): _________________________________________________________________________________
Dates from: _____________________________________________ Dates to: ___________________________________________
Total of hours: __________________________________________
Type of Childcare:
Babysitting
Au Pair
Tutoring
Youth Group
Day Care
Other
Weekly
Monthly
If other, please describe:
Frequency:
Daily
Responsibilities: ____________________________________________________________________________________________
4 (17)
APF July 2013

Phone: +1 866-428-7247
Fax: +1 707-658-2393
Au Pair Application
Total of hours: __________________________________________
Type of Childcare:
Babysitting
Au Pair
Tutoring
Youth Group
Day Care
Other
Weekly
Monthly
Frequency:
Daily

Total of hours: __________________________________________
Type of Childcare:
Babysitting
Au Pair
Tutoring
Youth Group
Day Care
Other
Weekly
Monthly
Frequency:
Daily
5 (17)
APF July 2013

Phone: +1 866-428-7247
Fax: +1 707-658-2393
Au Pair Application
Total of hours: __________________________________________
Type of Childcare:
Babysitting
Au Pair
Tutoring
Youth Group
Day Care
Other
Weekly
Monthly
Frequency:
Daily

Total of hours: __________________________________________
Type of Childcare:
Babysitting
Au Pair
Tutoring
Youth Group
Day Care
Other
Weekly
Monthly
Frequency:
Daily
6 (17)
APF July 2013

Phone: +1 866-428-7247
Fax: +1 707-658-2393
Au Pair Application
Total of hours: __________________________________________
Type of Childcare:
Babysitting
Au Pair
Tutoring
Youth Group
Day Care
Other
Weekly
Monthly
Frequency:
Daily
Preferred Age Groups (Check appropriate groups)

324 months
510 years
25 years
Over 10 years
Will you care for children with special needs?
Yes
No
Maximum number of children you will care for:

1
Host Family Preferences

APF will place you with a family suitable to your age, experience and background.
If you do NOT wish to be placed with a family like the following, please select it below.
Single parent family
Family of different religion
Family of a different race
Same sex (gay) family
Other. Please describe: ___________________________________________________________________________________

Would you accept placement with a family that has pets?
Yes
No
7 (17)
APF July 2013

Phone: +1 866-428-7247
Fax: +1 707-658-2393
Au Pair Application
Au Pair Application
Au Pair Hobbies: Please check the activities you practice or feel comfortable with:
swim
ski
tennis
basketball
running
trekking/ hiking
soccer
fishing
arts & crafts
music
dance
cook
other(s). Please describe: ___________________________________________________________________________

other(s). Please describe: __________________________________________________________________________________
Please list any other hobbies or skills that you want to share with a Host Family:
Do you have a first aid certification?

Yes
No
Other Certification? _________________________________________________________________________________
Au Pair Family Background

Fathers Name: _________________________________________ Occupation: _________________________________________
Mothers Name: ________________________________________ Occupation: _________________________________________
Address: ______________________________________________ City: ________________________________________________
Country: ___________________________________________________________________________________________________
Telephone Number: _____________________________________ Cell Number: ________________________________________
Number of siblings: _____________________________________ Place in birth order: ___________________________________
Religious Affiliation: ____________________________________ Attendance Frequency: ________________________________
Is your family supportive of your decision to come to America?
Yes
No
8 (17)
APF July 2013

Phone: +1 866-428-7247
Fax: +1 707-658-2393
Au Pair Application
Au Pair Application
Au Pair Employment History (dont list jobs already listed in the Childcare Experience section)
Present Occupation: _________________________________________________________________________________________
Employer: __________________________________________________________________________________________________
Dates of Employment
From: ___________________________ To: ____________________________
Address: ___________________________________________________________________________________________________
Telephone: _________________________________________________________________________________________________
Prior Occupation: ___________________________________________________________________________________________

Employer: __________________________________________________________________________________________________
Dates of Employment
From: ___________________________ To: ____________________________
Address: ___________________________________________________________________________________________________
Telephone: _________________________________________________________________________________________________
Personal Information: ( Please answer the follow questions truthfully by indicating yes or no)
Do you get homesick?
Yes
No
Have you lived away from home?
Yes
No
Have you lived out of the country?
Yes
No
Have you taken illegal drugs?
Yes
No
Do you drink alcoholic beverages?
Yes
No
Do you smoke?
Yes
No
Do you have racial prejudices?
Yes
No
Do you have any traffic tickets/ violations?
Yes
No
Have you been in a traffic accident?
Yes
No
Are you currently in a steady relationship?
Yes
No
9 (17)
APF July 2013

Phone: +1 866-428-7247
Fax: +1 707-658-2393
Au Pair Application
Au Pair Application
Have you ever been married?
Yes
No
Do you have a criminal record?
Yes
No
Do you have any financial commitments?
Yes
No
Do you have any physical or mental limitations?
Yes
No
Are you currently taking any medication?
Yes
No
Do you have any medical conditions that require treatment?
Yes
No
Do you have any allergies?
Yes
No
Are you a vegetarian?
Yes
No
If you are a vegetarian,

can you cook or be placed with a family that eats meat?
Yes
No
Please give a brief explanation to any items for which you answered yes:
What are the reasons why you want to be an Au Pair?
What are your goals in the 5 years following the Au Pair Program?
How will the Au Pair Program help you reach your future goals?
10 (17)
APF July 2013

Phone: +1 866-428-7247
Fax: +1 707-658-2393
Au Pair Application
Au Pair Application
Applicant Letter to Host Family
Please use the following space to write a letter to your future Host Family. In the letter, please describe yourself, your hobbies and
interests, your reasons for applying to the Au Pair program, and your plans for the future. This letter will give prospective Host
Families a first impression of you, and they may decide to interview you based on what is stated in this letter. This is your opportunity
to tell Host Families how great you are!
11 (17)
APF July 2013

Phone: +1 866-428-7247
Fax: +1 707-658-2393
Au Pair Application
Au Pair Childcare Reference 1 Form

Instructions
Please ask employer to complete this form in English if possible. Remember you may NOT use family members as primary references; however they can be used as supporting references.
Name of Applicant: __________________________________________________________________________________________
Name of Employer: __________________________________________________________________________________________
Street Address: _________________________________________ City/State: __________________________________________
Telephone: ____________________________________________ Best time to call: ______________________________________
How long have you know the applicant? ________________________________________________________________________
Childcare experience
Dates of Childcare: __________________________________________________________________________________________
Type of Childcare:
Babysitting
Au Pair
Tutoring
Youth Group
Day Care
Other
If other, please describe: ______________________________________________________________________________________

List duties performed: ________________________________________________________________________________________
Describe the applicants personality: ____________________________________________________________________________
Would you recommend this applicant for placement as an Au Pair in the Unites States? (Please elaborate)
Any additional comments? ____________________________________________________________________________________
Reference Signature: ____________________________________________________ Date: _______________________________
FOR OVERSEAS PARTNER USE ONLY:
VERIFIED BY: _________________________________________________
DATE: ____________________ SIGNATURE: _________________________________________________________________

12 (17)
APF July 2013

Phone: +1 866-428-7247
Fax: +1 707-658-2393
Au Pair Application
Au Pair Childcare Reference 2 Form

Instructions
Name of Employer: __________________________________________________________________________________________
How long have you know the applicant? ________________________________________________________________________
Childcare experience
Dates of Childcare: __________________________________________________________________________________________
Type of Childcare:
Babysitting
Au Pair
Tutoring
Youth Group
Day Care
Other.
If other, please describe: ______________________________________________________________________________________

List duties performed: ________________________________________________________________________________________
Describe the applicants personality: ____________________________________________________________________________
Would you recommend this applicant for placement as an Au Pair in the Unites States? (Please elaborate)
Any additional comments? ____________________________________________________________________________________
Reference Signature: ____________________________________________________ Date: _______________________________
VERIFIED BY: _________________________________________________
DATE: ____________________ SIGNATURE: _________________________________________________________________

13 (17)
APF July 2013

Phone: +1 866-428-7247
Fax: +1 707-658-2393
Au Pair Application
Au Pair Character Reference Form

Instructions
Name of Reference: _________________________________________________________________________________________
How long have you know the applicant? ____________________ Relationship to Applicant: ______________________________
Please rate the applicant in the following areas:

Communication Skills:
Excellent
Good
Fair
Poor
Dont know
Reliability:
Excellent
Good
Fair
Poor
Dont know
Work Quality:
Excellent
Good
Fair
Poor
Dont know
Maturity:
Excellent
Good
Fair
Poor
Dont know
Friendliness:
Excellent
Good
Fair
Poor
Dont know
Manners:
Excellent
Good
Fair
Poor
Dont know
Attitude:
Excellent
Good
Fair
Poor
Dont know
Grooming:
Excellent
Good
Fair
Poor
Dont know
Ability to handle stress:
Excellent
Good
Fair
Poor
Dont know
Ability to handle emergencie:
Excellent
Good
Fair
Poor
Dont know
Ability to work with others:
Excellent
Good
Fair
Poor
Dont know
Ability to relate to children:
Excellent
Good
Fair
Poor
Dont know
Please describe the applicants strengths and weaknesses:
Please describe the applicants personality:
Reference Signature: _____________________________________________ Date: ______________________________________
VERIFIED BY: _________________________________________________
DATE: ____________________ SIGNATURE: _________________________________________________________________

14 (17)
APF July 2013

Phone: +1 866-428-7247
Fax: +1 707-658-2393
Au Pair Application
Au Pair Statement of Health Form

Part A. To Be Completed by Applicant
Au Pair Applicant Name: ______________________________________________________________________________________
Gender:
Male
Female
Height:____________________ Weight: _________________________________________________________________________

Are you covered by additional insurance other than that provided by Au Pair Foundation?
If yes, please describe:
Yes
No
Medical History
Have you ever had any of the following medical conditions? Please select any that apply.
Tuberculosis
Mumps
Rheumatic Fever
Ulcers
Dizziness/Fainting
Asthma
Chicken Pox
Anorexia
Gall Bladder Problems
Venereal Disease
Allergies
Heart Disease
Diabetes
Glandular fever
Bulimia
Depression
Epilepsy/ Convulsion
Anemia
German Measles
Arthritis
Ear Infection
Eye Problems
Headaches
Scarlet Fever
Menstrual Problems
Pregnancy
Miscarriage
Other
Please provide details, including dates of condition, of any of conditions selected above:
Have you ever undergone surgery?
Yes
No
Is your physical activity restricted in anyway?
Yes
No
Have you ever received treatment for nervous or emotional problems?
Yes
No
Have you ever been treated by psychiatrist?
Yes
No
If yes, please give full details with date:
15 (17)
APF July 2013

Phone: +1 866-428-7247
Fax: +1 707-658-2393
Au Pair Application

Are you currently taking any medications?
Yes
No
Do you have any of the following habits that affect your health?
Yes
No
Do you have any chronic or recurring illness?
Yes
No
Have you ever been tested for AIDS?
Yes
No
If yes, please give full details including medication name or dosage:
If yes, have you ever been diagnosed HIV positive?
Part B. To be completed by the Physician

As an Au Pair, the applicant will be living for an extended period of time in the home of a family with young children. It is therefore important that we are advised of any physical or mental health issues that may have a bearing on the applicants ability to
participate.
A. Please review the information provided by the applicant above.

B. Please indicate whether the applicant has been immunized against the following:
Tetanus
Yes
No
Date: _____________________________
Diphtheria
Yes
No
Date: _____________________________
Typhoid
Yes
No
Date: _____________________________
TB
Yes
No
Date: _____________________________
Polio
Yes
No
Date: _____________________________
Measles
Yes
No
Date: _____________________________
Mumps
Yes
No
Date: _____________________________
Whooping Cough
Yes
No
Date: _____________________________
16 (17)
APF July 2013

Phone: +1 866-428-7247
Fax: +1 707-658-2393
Au Pair Application

C. Are there any abnormalities of the following systems?
Gastrointestinal
Yes
No
Skin
Yes
No
Metabolic
Yes
No
Eyes
Yes
No
Musculoskeletal
Yes
No
Neuropsychiatric
Yes
No
Genitourinary
Yes
No
Other
Yes
No
Please provide details, including dates of condition, of any abnormalities indicated above:
D. Is the applicant currently being treated or recently been treated/counseled for a nervous condition, depression or
emotional disorder?
Yes
No
If yes, please explain:
E. Is there, in your opinion, any condition, either physical or emotional, which an American family should consider
when deciding to have the applicant live in their home and care for their small children for one year?
Yes
No
f yes, please explain:
F. How long have you treated this patient? ____________________________________________________________

Comments: ________________________________________________________________________________________________
Name of Doctor: ____________________________________________________________________________________________
Address: ______________________________________________________________ Phone: ______________________________
Doctors Signature______________________________________________________ Date: ________________________________
17 (17)
APF July 2013

Phone: +1 866-428-7247
Fax: +1 707-658-2393

Au Pair Application PDF

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Au Pair Application Packet

Applicant Name: ____________________________________________________________________________________________

Au Pair Foundation Internal Use Only

I.D. Number: _______________________________________________________________________________________________

APF July 2013

205 Keller Street, Suite 204

Family Name: __________________________________________ First Name: __________________________________________

Date of Birth (mm/dd/yyyy):_____________________________

City of Birth: ___________________________________________ Country of Birth: ______________________________________

If yes, when did you receive it? _________________________________________________________________________________

APF July 2013

205 Keller Street, Suite 204

Emergency Contact Information

APF July 2013

205 Keller Street, Suite 204

Childcare Experience with Age Groups (Check appropriate groups)

I have 200 hours of documented Infant Care Experience:

Do you have experience with children with special needs?

Describe any special needs experience: __________________________________________________________________________

Childcare Experience 1 (Please list youngest childcare experience first)

If other, please describe:

APF July 2013

205 Keller Street, Suite 204

If other, please describe:

Childcare Experience 3 (Please list youngest childcare experience first)

If other, please describe:

APF July 2013

205 Keller Street, Suite 204

If other, please describe:

Childcare Experience 5 (Please list youngest childcare experience first)

If other, please describe:

APF July 2013

205 Keller Street, Suite 204

If other, please describe:

Preferred Age Groups (Check appropriate groups)

Will you care for children with special needs?

Maximum number of children you will care for:

Host Family Preferences

Family of different religion

Family of a different race

Same sex (gay) family

Other. Please describe: ___________________________________________________________________________________

APF GLOBAL EXCHANGE, NFP

APF July 2013

205 Keller Street, Suite 204

arts & crafts

other(s). Please describe: ___________________________________________________________________________

Do you have a first aid certification?

Au Pair Family Background

APF July 2013

205 Keller Street, Suite 204

From: ___________________________ To: ____________________________

Prior Occupation: ___________________________________________________________________________________________

From: ___________________________ To: ____________________________

Have you lived away from home?

Have you lived out of the country?

Have you taken illegal drugs?

Do you drink alcoholic beverages?

Do you have racial prejudices?

Do you have any traffic tickets/ violations?

Have you been in a traffic accident?

Are you currently in a steady relationship?

Family Name: First Name:

City of Birth: _____ Country of Birth:

From: _ To: __

From: _ To: __

Reference Signature: ______________________ Date: _

DATE: SIGNATURE: _____________________________________________

Reference Signature: ______________________ Date: _

DATE: SIGNATURE: _____________________________________________

Reference Signature: _______ Date:

DATE: SIGNATURE: _____________________________________________

Height: Weight: _____________________________________________________