Already Been Vaccinated - With What Vaccine?

AGENCY: APPLICATION FORM AU PAIR
SMILING
(PLEASE ANSWER ALL QUESTIONS AND SIGN AT PAGE 10, WE CAN NOT PLACE YOU UNLESS YOUR
APPLICATION FORM IS COMPLETED AND SIGNED!!) PICTURE
HERE
FIRST NAME: PEDRO
SURNAME: PEZUK
MIDDLE NAME(S): NICOLAS
 FEMALE  THIS CANDIDATE IS PART OF

THE AU PAIR STAR PROGRAM

x MALE
(COMPLETED COURSE ON FEB 20, 2023)

Are you planning on getting vaccinated against Covid-19?
 YES +971562942680
FEB 20, 2023 +971562942680
 NO nicopezuk@gmail.com
x
Already been vaccinated - with what vaccine? _________________________
Moderna and Sinopharm PEDRO NICOLAS PEZUK
Does not apply
CURRENT MAILING ADDRESS 21st Century Tower, Sheikh Zayid Road, Dubai, 00000, United Arab Emirates.
(HOME) TELEPHONE NUMBER +971562942680

CELL PHONE NUMBER +971562942680
E-MAIL nicopezuk@gmail.com
SKYPE NAME PEDRO NICOLAS PEZUK
HOME MAILING ADDRESS does not apply
(if different from above)
AGE
BIRTH DATE (DAY/MONTH/YEAR)
PLACE OF BIRTH
COUNTRY OF BIRTH
HEIGHT (IN METERS)
WEIGHT(IN KILOGRAMS)
HAIR COLOUR
EYE COLOUR
NATIONALITY
COUNTRY ISSUING YOUR PASSPORT
PASSPORT NUMBER
IF YOU DON’T HAVE A PASSPORT YET, WHICH DATE DID YOU APPLY FOR ONE?
Page 1 of 10
House o Orange South Africa Au Pairs Cultural Exchanges cc
16 Die Bad Pad/Road, Melkbosstrand, 7441
Phone: + 27 21 553 3638 / info@house-o-orange.co.za / www.house-o-orange.com
Cc: 2009/152982/23 Member: Ellen Hiemstra (NL)
APPLICATION FORM AU PAIR
ARE YOU, OR HAVE YOU EVER BEEN MARRIED?  YES  NO

IF YES, PLEASE SPECIFY:
ARE YOU, OR HAVE YOU EVER BEEN ENGAGED?  YES  NO

DO YOU HAVE CHILDREN OF YOUR OWN?  YES  NO

HAVE YOU EVER BEEN PREGNANT?  YES  NO
IF YOU ANSWERED ‘YES’ TO ONE OF THE ABOVE QUESTIONS, PLEASE SPECIFY:
HAVE YOU EVER BEEN ARRESTED?  YES NO

HAVE YOU EVER BEEN IN TROUBLE WITH THE LAW IN ANOTHER COUNTRY?  YES NO
DO YOU HAVE ANY CRIMINAL CONVINCTIONS?  YES  NO
IF YOU ANSWERED ‘YES’ TO ONE OF THE ABOVE QUESTIONS, PLEASE SPECIFY:
DO YOU HAVE ANY PHYSICAL DISABILTIES?  YES  NO

IF YES , PLEASE DESCRIBE YOUR DISABILITY AND HOW IT AFFECTS YOUR DAY-TO-DAY LIFE:
DO YOU ENJOY GOOD HEALTH?  YES  NO

IF NOT, PLEASE DESCRIBE YOUR HEALTH PROBLEMS:
HOW MANY DAYS HAVE YOU MISSED DUE TO ILLNESS IN THE PAST 12 MONTHS?
HAVE YOU EVER FEQUENTLY OR ARE YOU CURRENTLY USING ANY DRUGS?  YES  NO
IF YES , PLEASE SPECIFY WHAT KIND OF DRUGS AND ON WHAT BASIS (I .E DAILY, WEEKLY, SEASONAL):
DO YOU USE ANY MEDICATION(S)?  YES  NO

IF YES , PLEASE SPECIFY WHAT KIND OF MEDICATION AND ON WHAT BASIS (I .E DAILY, WEEKLY, SEASONAL):
HAVE YOU BEEN TREATED FOR DEPRESSION, ADD/ADHD OR MENTAL ILLNESS?  YES  NO
IF YES , PLEASE DESCRIBE THE SITUATION, HOW LONG AGO THIS WAS AND THE TREATMENT:
Page 2 of 10
HAVE YOU EVER SUFFERED FROM AN EATING DISORDER?  YES  NO

IF YES , PLEASE DESCRIBE THE SITUATION AND HOW LONG AGO THIS WAS:
DO YOU HAVE ANY ALLERGIES?  YES  NO

IF YES , PLEASE DESCRIBE YOUR ALLERGIES AND HOW IT AFFECTS YOUR DAY -TO-DAY LIFE:
DO YOU SMOKE?  YES  NO

IF YES: HOW MANY CIGARETTES PER DAY?
WILL YOU BE ABLE TO REFRAIN FROM SMOKING IN THE
HOUSE, AROUND THE CHILDREN AND DURING WORKING  YES  NO
HOURS?
IF NO: HAVE YOU EVER SMOKED?  YES  NO
IF YES, WHEN DID YOU QUIT?
IF YES, HOW LONG DID YOU SMOKE?
DO YOU HAVE A SPECIAL DIET?  YES  NO

IF YES, WHAT KIND OF DIET?
ARE YOU WILLING AND ABLE TO PREPARE YOUR OWN MEALS?  YES  NO
ARE YOU WILLING TO PREPARE ITEMS THAT YOU DO NOT EAT FOR THE
FAMILY AND/OR CHILDREN IN YOUR CARE?
 YES  NO
CAN YOU DRIVE?  YES  NO

IF YES: DRIVERS LICENCE NO:
WHEN DID YOU PASS?
WHAT TYPE OF VEHICLE DID YOU DRIVE IN THE PAST
12 MONTHS?
HOW OFTEN DID YOU DRIVE IN THE PAST 12 MONTHS?
CAN YOU DRIVE A STICK SHIFT?  YES  NO
CAN YOU DRIVE AN AUTOMATIC?  YES  NO
CAN YOU DRIVE IN THE CITY?  YES  NO
CAN YOU DRIVE IN THE COUNTRY SIDE?  YES  NO
WOULD YOU FEEL COMFORTABLE DRIVING FOR YOUR HOST FAMILY?  YES  NO
CAN YOU CYCLE?  YES  NO

IF YES: HOW OFTEN DO YOU CYCLE?
WHEN WAS THE LAST TIME YOU CYCLED?
AT WHAT AGE DID YOU LEARN TO CYCLE?
WHERE DID YOU LEARN TO CYCLE?
Page 3 of 10
IN WHAT KIND OF AREA ARE YOU USED TO CYCLE?

(CITY, COUNTRY SIDE ETC...)
WOULD YOU FEEL COMFORTABLE CYCLING FOR
YOUR HOST FAMILY?
IF NO: WOULD YOU BE WILLING TO LEARN TO CYCLE?
CAN YOU SWIM?  YES  NO

IF YES: HOW OFTEN DO YOU SWIM?
WHEN WAS THE LAST TIME YOU SWAM?
AT WHAT AGE DID YOU LEARN TO SWIM?
WHO TAUGHT YOU TO SWIM?
WHERE DID YOU LEARN TO SWIM?
DO YOU HAVE ANY SWIMMING CERTIFICATES?
IF NO: ARE YOU HYDROPHOBIC (FEAR OF WATER)?
DO YOU HAVE ANY OTHER SKILLS WHICH MAY BE USEFUL AS AN AU PAIR?  YES  NO
IF YES, SPECIFY:
WHAT LANGUAGES DO YOU SPEAK AND TO WHAT LEVEL?

(CHECK ONE BOX PER LANGUAGE SPOKEN)
Language Native Fluent Good Sufficient Basic Very basic N/A
ENGLISH       
AFRIKAANS       
DUTCH       
GERMAN       
FRENCH       
SPANISH       
OTHER(please specify)
      
WOULD YOU LIKE TO ATTEND LANGUAGE CLASSES ABROAD?  YES  NO

IF YES, LEASE SPECIFY WHICH LANGUAGE AND WHY :
ABOUT YOUR FAMILY:

FATHER (NAME, NATIONALITY AND OCCUPATION)
MOTHER (NAME, NATIONALITY AND OCCUPATION)
Page 4 of 10
MY PARENTS ARE…  MARRIED  DIVORCED

NAMES AND AGES OF BROTHERS:
NAMES AND AGES OF SISTERS:
PLEASE GIVE A SHORT DESCRIPTION OF YOUR FAMILY AND THE BOND YOU HAVE WITH THEM:
HAVE YOU EVER LIVED AWAY FROM HOME?  YES  NO

IF YES, PLEASE SPECIFY (FOR HOW LONG AND WHAT REASON):
RELIGION:
PRACTISING?  YES  NO
DO YOU EXPECT TO ATTEND RELIGIOUS SERVICES IN HOLLAND?  YES  NO
WOULD IT BE A PROBLEM FOR YOU IF YOU CANNOT GO TO CHURCH EVERY SUNDAY?  YES NO
ANY DIETARY OR OTHER RESTRICTIONS BECAUSE OF YOUR RELIGION?  YES NO
IF YOU HAVE ANSWERED YES TO ONE OF THE ABOVE QUESTIONS, PLEASE SPECIFY:
ARE YOU A STUDENT?  YES  NO

IF YES, SPECIFY:  HIGH SCHOOL  COLLEGE  UNIVERSITY OTHER:
WHAT ARE YOU MAJORING IN? (IF APPLICABLE)
WHEN DO YOU EXPECT TO GRADUATE ? (DATE)
IF NO, HIGHEST LEVEL OF EDUCATION REACHED:

 HIGH SCHOOL DIPLOMA*
 GRADE 10/11/12/13
 COLLEGE DIPLOMA*
 UNIVERSITY DIPLOMA*
*PLEASE INCLUDE DATE OF GRADUATION AND MAJOR (IF APPLICABLE):
GRADUATION DATE: MAJOR:
HIGH SCHOOL NAME:

HIGH SCHOOL ADDRESS:
Page 5 of 10
IF YOU ARE NOT A STUDENT WHAT IS YOUR PRESENT OCCUPATION?
IF YOU HAVE ANY WORK EXPERIENCE (APART FROM CHILDCARE EXPERIENCE), PLEASE SPECIFY;
JOB DESCRIPTION YRS/MNTHS
DESCRIBE BELOW ALL YOUR CHILD CARE EXPERIENCE (LISTING AGES OF CHILDREN AND
YOUR DUTIES) IN AS MUCH DETAIL AS POSSIBLE (PLEASE INCLUDE THE NUMBER OF
HOURS PER WEEK SPENT WITH THE CHILDREN AND THE TOTAL PERIOD OF TIME
INVOLVED AS WELL AS THE YEAR AND MONTHS YOU LOOKED AFTER THEM)
ARE YOU PREPARED TO TAKE CARE OF A BABY (3 MONTHS - 1 YR OLD)?  YES  NO

IF NOT, PLEASE SPECIFY:
I HAVE EXPERIENCE WORKING WITH:

 3 MONTHS – 1 YEAR  1-3 YEARS 4-7 YEARS 8-12 YEARS
I WOULD LIKE TO WORK WITH:
 3 MONTHS – 1 YEAR 1-3 YEARS 4-7 YEARS 8-12 YEARS
DO YOU HAVE EXPERIENCE WITH SPECIAL NEEDS CHILDREN?  YES  NO

WOULD YOU BE WILLING TO WORK WITH A SPECIAL NEEDS CHILD (AUTISTIC, PHYSICAL
DISABILITY, MENTAL DISABILITY ETC.)?
 YES
 NO
Page 6 of 10
 MAYBE, DEPENDING ON FAMILY/SITUATION

I WOULD LIKE TO WORK WITH THE FOLLOWING NO. OF CHILDREN:
1-3 CHILDREN  MORE THAN 3  NO PREFERENCE
WOULD YOU ACCEPT A SINGLE PARENT FAMILY?

 YES, SINGLE MOM
 YES, SINGLE DAD
 NO
HAVE YOU EVER DONE A FIRST AID COURSE?  YES  NO

DO YOU HAVE ANY FIRST AID DIPLOMA’S?  YES NO
HAVE YOU TAKEN ANY COURSE RELATED TO CHILDCARE?  YES NO
DO YOU HAVE ANY CHILD CARE QUALIFICATIONS?  YES NO
WILL YOU PARTICIPATE IN THE HOUSE O ORANGE AU PAIR TRAINING? YES  NO
IF YOU ANSWERED ‘YES’ TO ONE OF THE QUESTIONS ABOVE, PLEASE SPECIFY:
ARE YOU PREPARED TO DO LIGHT HOUSEWORK?  YES  NO

BELOW IS AN OVERVIEW OF LIGHT HOUSEHOLD CHORES EXPECTED FROM YOU BY THE
FAMILY, PLEASE LET US KNOW IF YOU’RE EXPERIENCED WITH ANY OF THESE CHORES.
(TICK BOX IF THE ANSWER IS ‘YES’)
EXPERIENCED WILLING TO LEARN
DOING LAUNDRY (MACHINE WASHING,
DRYING, SORTING AND FOLDING)
 
IRONING  
VACUMING  
PICKING UP AFTER THE CHILDREN  
SHOP FOR GROCERIES  
PREPARE DINNER  
HAND WASHING DISHES  
DISHWASHER PACKING/CLEARING  
CHANGING BED LINENS  
ARE THERE ANY TYPE OF HOUSEHOLD CHORES THAT YOU DO NOT WISH TO DO?  YES  NO
DO YOU KNOW HOW TO COOK? YES  NO

IF YES, PLEASE SPECIFY HOW MANY TIMES YOU COOK AND WHAT TYPE OF FOODS YOU NORMALLY COOK:
Page 7 of 10
HOW WOULD YOU DESCRIBE YOUR HOUSEKEEPING STYLE?

VERY NEAT NEAT MORE CASUAL MESSY
PLEASE SPECIFY:
WOULD YOU ACCEPT A FAMILY WITH:

DOGS?  YES  NO
CATS?  YES  NO
OTHER PETS?
IF NOT, PLEASE SPECIFY:
WOULD YOU BE WILLING TO HELP OUT WITH THE CARE OF PETS (I.E. WALK THE DOG, FEED THE CAT)?
 YES  NO
PLEASE SPECIFY YOUR ANSWER:
WHAT ARE YOUR INTERESTS AND HOBBIES:
DO YOU LIKE TO READ (TO THE CHILDREN)?

DO YOU LIKE TO DO ARTS AND CRAFTS (WITH THE CHILDREN)?
DO YOU LIKE TO SING AND/OR MAKE MUSIC (WITH THE CHILDREN)?
DO YOU LIKE WATCHING CHILDRENS DVD'S?
DO YOU LIKE TO "HORSE-PLAY" WITH CHILDREN?
WHAT ARE YOUR BEST PERSONALITY TRAITS?
WHAT ARE YOUR WORST PERSONALITY TRAITS?
Page 8 of 10
Page 9 of 10
WHAT DO YOU CONSIDER TO BE APPROPRIATE DISCIPLINE TECHNIQUES FOR

YOUNG CHILDREN?
WHAT ARE YOUR FAVORITE ACTIVITIES TO DO WITH CHILDREN?
WHAT DO YOU LIKE BEST ABOUT TAKING CARE OF CHILDREN?
WHAT DO YOU LIKE LEAST ABOUT TAKING CARE OF CHILDREN?
IN YOUR OWN WORDS, EXPLAIN YOUR MOTIVATION TO BECOME AN AU PAIR IN

HOLLAND, AND WHAT YOU HOPE TO FIND IN A HOST FAMILY:
Page 10 of 10
WHAT DO YOU PLAN TO DO AFTER COMPLETING YOUR AU PAIR ASSIGNMENT?
EARLIEST POSSIBLE DATE OF DEPARTURE :

LATEST POSSIBLE DATE OF DEPARTURE:
CAN YOU STAY FOR 12 MONTHS?  YES  NO
IF NOT, HOW LONG WOULD YOU BE PREPARED TO STAY?
PLEASE SPECIFY WHY YOU CANNOT MAKE A 12 MONTH COMMITMENT:
 I declare I have filled out this form myself, I have answered all questions truthfully and honestly and
I have understood my duties, rights and obligations as an au pair. By signing this document, I agree to
the program conditions as presented to me by House o Orange South Africa and on the website
www.house-o-orange.com. I will immediately inform my agency of any changes in my personal situation
and if necessary, I will fill out a new application form. I also declare that I have never been arrested or in
trouble with the law in any country. I am in good physical and mental health.
PLACE
DATE
SIGNATURE AU PAIR
Page 11 of 10

Already Been Vaccinated - With What Vaccine?

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Already Been Vaccinated - With What Vaccine?

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AGENCY: APPLICATION FORM AU PAIR

FIRST NAME: PEDRO

MIDDLE NAME(S): NICOLAS

 FEMALE  THIS CANDIDATE IS PART OF

(COMPLETED COURSE ON FEB 20, 2023)

(HOME) TELEPHONE NUMBER +971562942680

ARE YOU, OR HAVE YOU EVER BEEN MARRIED?  YES  NO

ARE YOU, OR HAVE YOU EVER BEEN ENGAGED?  YES  NO

DO YOU HAVE CHILDREN OF YOUR OWN?  YES  NO

HAVE YOU EVER BEEN ARRESTED?  YES NO

DO YOU HAVE ANY PHYSICAL DISABILTIES?  YES  NO

DO YOU ENJOY GOOD HEALTH?  YES  NO

DO YOU USE ANY MEDICATION(S)?  YES  NO

HAVE YOU EVER SUFFERED FROM AN EATING DISORDER?  YES  NO

DO YOU HAVE ANY ALLERGIES?  YES  NO

DO YOU SMOKE?  YES  NO

IF YES, WHEN DID YOU QUIT?

IF YES, HOW LONG DID YOU SMOKE?

DO YOU HAVE A SPECIAL DIET?  YES  NO

CAN YOU DRIVE?  YES  NO

CAN YOU CYCLE?  YES  NO

AT WHAT AGE DID YOU LEARN TO CYCLE?

WHERE DID YOU LEARN TO CYCLE?

IN WHAT KIND OF AREA ARE YOU USED TO CYCLE?

IF NO: WOULD YOU BE WILLING TO LEARN TO CYCLE?

CAN YOU SWIM?  YES  NO

AT WHAT AGE DID YOU LEARN TO SWIM?

WHO TAUGHT YOU TO SWIM?

WHERE DID YOU LEARN TO SWIM?

DO YOU HAVE ANY SWIMMING CERTIFICATES?

IF NO: ARE YOU HYDROPHOBIC (FEAR OF WATER)?

WHAT LANGUAGES DO YOU SPEAK AND TO WHAT LEVEL?

WOULD YOU LIKE TO ATTEND LANGUAGE CLASSES ABROAD?  YES  NO

ABOUT YOUR FAMILY:

MOTHER (NAME, NATIONALITY AND OCCUPATION)

MY PARENTS ARE…  MARRIED  DIVORCED

NAMES AND AGES OF SISTERS:

HAVE YOU EVER LIVED AWAY FROM HOME?  YES  NO

ARE YOU A STUDENT?  YES  NO

WHEN DO YOU EXPECT TO GRADUATE ? (DATE)

IF NO, HIGHEST LEVEL OF EDUCATION REACHED:

HIGH SCHOOL NAME:

IF YOU ARE NOT A STUDENT WHAT IS YOUR PRESENT OCCUPATION?

ARE YOU PREPARED TO TAKE CARE OF A BABY (3 MONTHS - 1 YR OLD)?  YES  NO

I HAVE EXPERIENCE WORKING WITH:

DO YOU HAVE EXPERIENCE WITH SPECIAL NEEDS CHILDREN?  YES  NO

 MAYBE, DEPENDING ON FAMILY/SITUATION

WOULD YOU ACCEPT A SINGLE PARENT FAMILY?

HAVE YOU EVER DONE A FIRST AID COURSE?  YES  NO

ARE YOU PREPARED TO DO LIGHT HOUSEWORK?  YES  NO

DO YOU KNOW HOW TO COOK? YES  NO

HOW WOULD YOU DESCRIBE YOUR HOUSEKEEPING STYLE?

WOULD YOU ACCEPT A FAMILY WITH:

WHAT ARE YOUR INTERESTS AND HOBBIES:

DO YOU LIKE TO READ (TO THE CHILDREN)?

WHAT ARE YOUR BEST PERSONALITY TRAITS?

WHAT ARE YOUR WORST PERSONALITY TRAITS?

WHAT DO YOU CONSIDER TO BE APPROPRIATE DISCIPLINE TECHNIQUES FOR

WHAT ARE YOUR FAVORITE ACTIVITIES TO DO WITH CHILDREN?

WHAT DO YOU LIKE BEST ABOUT TAKING CARE OF CHILDREN?

WHAT DO YOU LIKE LEAST ABOUT TAKING CARE OF CHILDREN?

IN YOUR OWN WORDS, EXPLAIN YOUR MOTIVATION TO BECOME AN AU PAIR IN