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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: ___________________________________________________________________________________

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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 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
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 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

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 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

Childcare Experience
Childcare Experience 2 (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: ____________________________________________________________________________________________

Childcare Experience 3 (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: ____________________________________________________________________________________________

5 (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

Childcare Experience
Childcare Experience 4 (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: ____________________________________________________________________________________________

Childcare Experience 5 (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: ____________________________________________________________________________________________

6 (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

Childcare Experience
Childcare Experience 6 (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: ____________________________________________________________________________________________

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 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

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 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

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 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

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 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

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 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

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
Ages and names of child(ren): _________________________________________________________________________________
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 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

Au Pair Childcare Reference 2 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
Ages and names of child(ren): _________________________________________________________________________________
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: _________________________________________________________________


13 (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

Au Pair Character Reference 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 Reference: _________________________________________________________________________________________
How long have you know the applicant? ____________________ Relationship to Applicant: ______________________________
Street Address: _________________________________________ City/State: __________________________________________
Telephone: ____________________________________________ Best time to call: ______________________________________

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: ______________________________________

FOR OVERSEAS PARTNER USE ONLY:

VERIFIED BY: _________________________________________________

DATE: ____________________ SIGNATURE: _________________________________________________________________


14 (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

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 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

Au Pair Statement of Health Form


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 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

Au Pair Statement of Health Form


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 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