http://www.videojug.

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Reg. no. 2007/233816/23

268 Bryanston Drive

Bryanston

2191

South Africa

Tel: 011 463-4438

Fax: 086 619-5491

Cell: 082 603-3512

enquiries@aupair-extraordinaire.co.za

www.aupair-extraordinaire.co.za

Au Pair

Extraordinaire

For parents who care

AU PAIR QUESTIONNAIRE

Where did you hear about Au Pair Extraordinaire?

DETAILS OF AU PAIR

Surname

First names

Nationality

ID number

Tel: Home

Tel Work

Cell

Email address

Postal address

Residential address
Religion

Language spoken at home

Other languages spoken

Marital status

Do you have children?

If yes, please give ages and genders

Do they live with you?

Do you have a criminal record?

__________________________________________________________

Have you ever abused drugs and / or alcohol? If yes, please describe.
____________________________

_________________________________________________________________________________
___Do you have a criminal record?

Are you honest and trustworthy?

Father’s profession

Mother’s profession

Brothers’ ages

Sisters’ ages

Your current occupation

When would you like to start?

Do you have any health problems?

If yes, please describe

Do you smoke?

If yes, how many per day

Would you be prepared not to smoke during working hours?

Do you like pets?

Do you have a driver’s licence?

If yes, for how many years?

Do you have your own motor vehicle?

If yes, please give details

How many traffic violations have you been fined for in the past 2 years?

Please give details

Highest level of education

Which subjects did you take at matric level?

_________________________________________________

__________________________________________________________________________________
__

CHILDCARE EXPERIENCE

Have you been an au pair before?

Please describe in detail your previous childcare experience

Please give details of childcare courses you have attended and provide
certificates or confirmations of these

Do you have any experience working with special needs children?

If yes, please describe

Will you be happy to au pair for children with special needs?

Are you able to prepare basic meals, such as lunch for the children you will be
caring for?

Are you capable of looking after babies?

If so, from what age?

What ages of children would you like to au pair for?

Do you have a preference for gender of the children?

Is there anything else you feel is necessary for prospective families to be aware?

Why do you want to be an au pair?

________________________________________________________

__________________________________________________________________________________
__

WORKING HOURS
Hours you are available to work

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

What rate per hour do you require?

Agreed upon working hours? R

Overtime R

Babysitting R

I confirm that I have completed this questionnaire as comprehensively as

possible and that all information

provided is true and correct to the best of my knowledge. I agree to abide by the
terms and conditions of Au

Pair Extraordinaire and have clarified any uncertainties.

DATE

SIGNATURE OF APPLICANT

Au-Pair - Registration Form

To become a au-pair we need some information from you. Please fill all questions truely.
We also need some references, pictures and a medical certificate. Please send us this infromation by post or by email.
We are looking to your registration.
Haut du formulaire

Name:

First Name:

Gender: female male

Street:

Postcode:
City:

Country:

Phone:

Fax:

E-Mail:

Wish-Countrys:

Earliest beginn of your au-pair activity:

Length of stay: 6 month 12 month

Nationality: Religion:

place of
Date of birth:
birth:

Size: Weight:

Education / Profession?

actual employment?

your hobbies?

Name of Father:

Profession:
Name of Mother:

Profession:

Count of silbings:

Age of Silbings

Do you have some experiences with children?

Are you able to care for handicapped children?

Yes No

Do you have experiences with babies?

Yes No

Would you like to live in a single parent family? Mother Vater

No
Which experiences do you have in housework?

Can you cook?

Yes No
If yes, what would you like to cook?

Do you like pets?

Yes No

Do you smoke?
Yes No

Would you turn done smoking at the hostfamily?

Yes No
Can you swim?
Yes No

Do you have a driving licence?

Yes No

Are you vegetarian?

Yes No

Do you play a musical instrument?

Yes No

If yes which musical instrument?

Do you have any allergy?

Yes No

If yes, which allergy do you have?

City countrifie
Which residential area do you perfer?

d whatever

(Please keep in mind, a placment in a countrified region could be faster)

How are your English-skills?

very good good satisfactory pass poorly

unlearned

Where and how long do you learned English?

Do you speak other languages?

Did you visit other countries? If yes, where and how long?

Your Interests? Your Conceivabilities? Why do you what to go abroad?

You assure that all information the TRUTH, when you send this form!

send clear

Bas du formulaire

Büro: +49 (0)5321 - 78 64 00

Fax: +49 (0)321 - 21 20 67 44

Copyright © Au-pair Agentur "Alice", 2005