Passei) de *r+%ia$ ,- .ti% /0 1-11- 2ar%e!ona Te!3 45 /67 8- 47 #%n9au&airinterna%iona!3%om w w w 3au&airinterna%iona!

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PASAPORTE Foto SONRIENTE

Country destination: ____

IMPORTANTE: Rellenar el cuestionario en INGLS. y en color azul fuerte.
First available start date: Lenth of stay(in months : Surname: First name: !ate of birth: %ome adress: $ostal code: 'arital status: Identity card number: 'obile tele*hone number: (,mail address: Reli#ion: %ei#ht: .ei#ht: City-town Nationality: ()*ire date: Home +ele*hone: S-y*e address: &ountry "#es: $lace of birth(country :

!o you acce*t a family /ith other reli#ion0

SI/YE S SI/YES

NO

NO

!o you have a clean *olice record0 .hat do you acce*t? (Cuanto ms !e"i#!e en e! sitio$ ms %i! y r&ida es !a %o!o%a%i'n( &ity Suburb of a lar#e city

SI/YES SI/YES SI/YES SI/YES

NO NO NO NO

+o/n

Re#ional

: .ill you acce*t *osition of (&uantas m1s horas hace m1s *oc-et money recibe
@EMI-ADPAIR 5-8 ;oras ADPAIR 7-<;oras ADPAIR PED> , ;oras MOTHER HEEP --4 ;oras

IMPORTANTE: (s muy im*ortante 2ue se ten#a nivel intermedio de idioma *ara 2ue *ueda comunicarse con la familia y los ni3os.

= !o you thin- you could s*ea- by email to your host family0 !o you thin- you could s*ea- little conversation by *one to your %ost family 0 (mer#ency contact number:.. >u ami!ia ? 4our family A&e!!ido ? Surname Nom#re 5 First name @ire%%i'n ? "ddress N3 de te!A ono?+ele*hone Pro esi'n 5 6ccu*ation Madre ? 'other

SI/YES SI/YES
Padre ? Father

NO NO

Names and a#es of sisters:

and brothers:

7N6.L(!G( 6F L(NG8"G(S 'other ton#ue:

%o/ lon# have you been learnin# the lan#ua#e of the country that you a**ly0

Es&aBo! ? S*anish In)!As ? (n#lish A!emn ? German Cran%As ? French

NADA / ANY

SUFICIENTE / INTERMEDIUM

BUENO/GOOD

EXCEL.LE NT

NADA / ANY NADA / ANY NADA / ANY

SUFICIENTE / INTERMEDIUM SUFICIENTE / IINTERMEDIUM SUFICIENTE / INTERMEDIUM

BUENO/GOOD BUENO/GOOD BUENO/GOOD

EXCEL.LE NT EXCEL.LE NT EXCEL.LE NT

 !o you -no/ any other lan#ua#e0

(!8&"+I6N "N! S7ILLS

Estudios rea!iFados ? Realitated studies: +iene al#una $rofesi9n ? $rofession: $resent occu*ation: E"&erien%ia )enera! en a!)Gn tra#aHo y en e! de %uidado de niBos ? .or- and /or- e)*erience /ith children:..((s*ecificar

Sites visited (+ravellin# : SI/YES = !o you have a valid drivin# license0 NO

%o/ often do you drive0 %o/ lon# did you have the drivin# license0 .ill you be able to drive in your host country0

SI/YES

NO

Es&e%i iIue %u!es son sus Ho##ies o a i%iones ? .hich are your hobbies0..

!o you *lay any musical instrument0

&an you s/im0

SI/YES

NO

!o you s-i0 SI/YES !o you -no/ ho/ to ride a bi-e0 NO

SI/YES

NO

!o you *lay tennis0

SI/YES

NO

!o you -no/ ho/ to ride a horse0

SI/YES

NO

%6. R("!4 "R( 468 F6R: POCO / LITTLE

&arin# for babies

FAIR ULAR FAIR

BIEN / GOOD

!ress children

POCO / LITTLE

BIEN / GOOD

7ee* children occu*ied; *layin# and *re*arin# activities.

POCO / LITTLE

FAIR

BIEN / GOOD

Su*ervision doin# the school home/or-.

POCO / LITTLE

REGULA R

BIEN / GOOD

!o you have first aid certificate +iene al#<n certificado de *rimeros au)ilios

Yes

No

(=$(RI(N&(S .I+% %68S(.6R7:

&ocina sencilla >&oo-in# POCO / LITTLE REGULA R BIEN / GOOD

Paste!eria ?a-in#

POCO / LITTLE

REGULA R

BIEN / GOOD

"yuda en lavar la ro*a !o laundry

POCO / LITTLE

REGULA R

BIEN / GOOD

Ayuda en !a &!an%;a de !a ro&a He!& &in) wit; %;i!dren Iron t;e %!ot;es

POCO /LITTLE

REGULA

BIEN / GOOD

RRRR

POCO / LITTLE lLIlilitLITTLE

POCO / LITTLE REGULA R BIEN / GOOD

Lim*ieza de la habitaci9n y ba3o de los ni3os. &lean children bedroom and bathroom.

Helping Tidying the kitchen alte the !a"ily #$e Helping t% p epa e& and tidy #p a!te "eal$'

Helping (illing and e"ptying di$h)a$he '

=Tiene a!)una e"&erien%ia %on niBos dis%a&a%itados? !o you have any e)*erience /or-in# /ith disabled children0 SI/YES NO

Esta dis&uesta a %uidar niBos dis%a&a%itados? "re you /illin# to care for a disabled child0

SI/YES

NO

=>a#rJa %o%inar &ara !os niBos? &ould you coo- for children0

SI/YES

NO

>ea !o ms !e"i#!e &ossi#!e en !as o&%iones &osi#!es ? ?e as fle)ible as *ossible in the available o*tions:

=A &artir de Iue edad estarJa dis&uesta a %uidar !os niBos? From /itch a#e of children /ould you be *re*ared to ta-e care0

=Ha estado de Au-&air anteriormente? %ave you ever been an au,*air0

SI/YES

NO

=En Iue PaJs y &or %uanto tiem&o?? In /hich country and for ho/ lon#0

Tiene e*pe iencia de c#ida ni+%$ en E$pa+a' Childca e in ,pain '

ACEPTARIA KIKIR CONL ? MODE@ NOD ACCEPT TO EIKE MITHL Madre so!a %on niBos Sin#le mom /ith children SI/YES NO

Padre so!o %on niBos Sin#le father /ith children

SI/YES

NO

>ENIOR PO>ITION Ayuda a &ersona mayor %el* to the older *eo*le SI/YES NO

E"&!iIue a!)unos de !os deta!!es de su e"&erien%ia en e! %uidado de niBos in%!uido edades y tareas rea!iFadas3 ? ()*lain in some /ords a detailed descri*tion of you e)*erience of child care and your rea!iFed tasOs3

Es%ri#ir!o en in)!As en este es&a%io a&ro"imado3

-------

S'67ING =Es usted umadora? !o you smo-e0 SI/YES NO

=Cuantos %i)ari!!os uma a! dJa? ? %o/ many ci#arettes do you smo-e *er day0

Acepta usted o !u"a# e la casa $ e p#ese cia de los i%os& E el caso de 'ue o cu"pla la o#"a puede (e#se despedida de la casa de i "ediato) / D% y%# ag ee t% e! ain ! %" $"%king in the h%#$e and in the p e$ence %! child en' I #nde $tand that i - eaking thi$ p %"i$e "ean that I "ay -e a$ked t% lea.e "y h%$t !a"ily.
SI/YES
CIRME >I ACEPTA EA CON@ICION si no uma &on)a IPM NO >MOQER

NO

N8+RI+I6N,!I(+ =Tiene Iue )uardar a!)Gn ti&o de dieta? !o you have any s*ecial eatin# habits0 SI/YES NO

>u re a!)una a!er)ia? !o you suffer from aller#ies0 SI/YES NO

$(+S

=A%e&ta %uidar de anima!es domAsti%os de !a %asa? "re you /ellin# to care for *ets0 YES
N

"cce*t *ets in the house0 Nes$ to a!! Nes$ to outside &ets No$ to do) No$ to %at

O O oo O No$ to a!!

P!ease )iRe t;e name$ address and te!e&;one num#er o two re eren%es (not re!atiRes( Name: Poblacin: Telephone: Name: Poblacin: Telephone:

Au &air a)reement
1. I (NAME(LLLLLLLLLLLLLLLLconfirm that I have read and understood all material provided and that I fulfil all criteria and agree to abide by the au pair program guideline. 2. I give permission to release all my information to potential host families. 3. I confirm that all information I have provided is honest, correct and complete. . !fter my confirmed placement I agree to stay in touch "ith the host family. #. I "ill not travel to the family until all details are confirmed by the agency. $. I understand that I need to arrange and pay for travel to%from my host country and insurance. &. I ensure Identity card and driver's license if I have are up to date, ready for travel and valid for the duration of stay. (. I "ill respect the family agreement and house rules and "ill carry out my duties to my best ability. ). I shall see* advice of the host family before using any form of discipline on the children and under no circumstances shall I hit the children or leave them alone. 1+. I understand that the success of the au pair e,perience depends largely on my initiative and fle,ibility to adapt. 11. -ithin the first "ee* of my placement, I "ill inform to the agent of my contact details. 12. If I have any problems or .uestions "hich I cannot resolve "ith the host family, I shall contact the local agency for assistance. 13. I "ill ma*e every effort to resolve any differences "ith my host family. If a solution is not found, I "ill give 1 days' notice and may apply for a ne" placement. /uring notice, duties and pay continue as normal unless by mutual agreement. I "ill inform the local agency of notice given. 1 . If I re.uest to be placed in a ne" family, I understand that this is do"n to the discretion of the agent 1#. I shall not hold the agency responsible for any losses, in0ury or damage 1$. I understand that my au pair program can be terminated if I fail to abide by this agreement, if I breach contract "ith the family or if there is a case of misconduct. 1his includes 2but is not limited to3 lying and falsification of documents. 4ignature 5555555555555 /ate 5555555555555.

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