Applicant Name: ID:

Childcare Reference
This applicant is applying to the Au Pair in America program which allows Au Pairs to live and study legally in the United States.
Au Pairs spend up to 2 years as an Au Pair Cultural Exchange Student within an American Host Family providing up to 45 hours of
childcare a week.
References are an important part of our screening process and we would like to request that you complete this reference form
and a local representative will then contact you.

How do you know the applicant? O Employer O Family Friend O Colleague O Neighbour O Teacher O Other

How long have you known the applicant? years months

Please rate the applicant on the following qualities

Excellent Very Good Good Average Poor

Understanding children’s needs O O O O O

Child health and safety O O O O O

Childcare duties O O O O O

Engaging children in activities O O O O O

Interacting with children O O O O O

Honesty O O O O O

Punctuality O O O O O

Flexibility O O O O O

Responsibility/Maturity O O O O O

Communication skills O O O O O

Independence O O O O O

Patience O O O O O

Ability to work with adults O O O O O

Ability to carry out instructions O O O O O

Warmth/Compassion O O O O O

Reliability O O O O O

Adaptability O O O O O

Ability to manage stressful situations O O O O O

Would you recommend the applicant to be an Au Pair in America? O Yes O No

Referee Name: Telephone Number:

Do you speak English? O YES O NO Best time to call:

Signature: Date: