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Au Pair International

Au Pair Application
Application checklist: i. All au pairs must submit child care references Completed application form (this form). documenting a minimum of 200 hours of child care Your criminal record transcript. i) experience. Au Pair Professionnel applicants must in Two non-family related child care references addition supply a copy of the appropriate child care One non-family related personal reference. qualifications or a reference confirming their professional Medical record verification form. child care experience. ii) Copies of your latest school diplomas ii. Copies of the latest school, academic and/or vocational Copy of your drivers license. certificates or diplomas you hold, or a letter from your Copy of your passport (the one page with personal info only). school/college verifying the dates you attended and the qualifications you gained. Please bring originals for Dear host family letter (1-2 pages). verification to your interview. Photo collage (maximum 2 pages, preferably digital). One passport photo (approx. 5cm by 5cm). NOTE: Please note that we can not return any of your application documents, including photographs or references at any time. Therefore, please keep a copy. Tips for filling out the application: Type or write neatly with black ink. Smile in the passport photo! Do not staple pages together. Do not cut pages. If possible, create the photo collage as a digital document (.doc, .pdf, .jpg) with typed photo captions. Focus on your child care experience in the application, photo collage and essay. Include skills and hobbies that might help you in your application (play piano, good swimmer, sports, etc.). Write your name at the top of all pages and attachments. Understand what you are signing. Criminal record: Contact you local police office to order a transcript/printout/certificate of your criminal record. Medical record form: Contact your physician to have the medical form filled out. Photo collage (1- 2 pages): The photos you choose should show you together with the children you have cared for, your family and/or friends. Arrange 4 to 6 photographs over the 1-2 white pages. Next to each photo, explain who is in the picture and what you are doing. Write your name at the top of each page. References: Collect a minimum of three (3) non-family related references (2 child care and 1 personal). References should be completed using the API reference forms. We encourage you to submit as many child care and character references as possible. Immediate family members may only provide additional references (in addition to the three minimum required). All references must be translated into English with the original attached. Dear host family letter: Your letter will help prospective host families get a better understanding of who you are. Provide examples of qualities and skills you have. Provide as much detail as you can to give a sense of your child care experience, activities you do with children and why you like caring for children. Your letter should be 1-2 pages long. Typed letters are preferable. Write your name at the top of each page. Make sure that you leave a 2 cm margin on all sides. Next: Contact us for an interviewer near you. Schedule the interview and bring your completed application to the interview.

Please include any additional comments that you feel should be considered (e.g. name and contact information if you already have a host family in the US, etc.) ________________________________________________________________ __________________________________________________________________________________________________

Au Pair International Au Pair Application 072706

Au Pair International Au Pair Application

(Please mark all programs that you would consider, if you qualify): (Min. 200 hours of documented child care experience) Au Pair Infant Qualified Au Pair (Min. 200 hours of documented infant (0-2 years old) child care experience) (Professional child care education or min. 2 years full-time child care experience) Au Pair Professionnel Please place a recent, smiling(!) passport photo here

Do you have a drivers license?



(see page 4 for more details)

PERSONAL INFORMATION (as it appears in your passport) (PLEASE PRINT) Name _______________________________________________________________________________ _______________ Full postal address ______________________________________________________________________________________ ______________________________________________________________________________________________________: ________________________________________________________________________ Country _____________________ Date of birth _______/_______ /_______ City and country of birth ______________________________________________ Passport no. _____________________________ Expiration date _______/_______/_______ Nationality _______________________________ Passport issued in ____________________________________________ Drivers license no. ________________________ Personal identification no. (if applicable) ______________________________ I am a: Female Male Height_________ Weight_________ Eye color_________ Hair color ________ Yes Yes No No What was the outcome? Denied Approved Yes No Have you visited the USA before? Have you ever applied for a visa to the USA? Have you been an au pair in the USA before? AVAILABILITY Earliest departure date_____/_____/_____ Latest departure date_____/_____/_____ Notice required at work_____________ Preferred departure airport(s) ________________________ Your nearest US Embassy (city) _________________________ If given the opportunity, would you consider extending your stay in the US*: If yes, for how long (months): 6 9 12 I dont know Yes No Maybe I dont know (*Visa extensions available for 6, 9, or 12 additional months)
Day Month Year Day Month Year Day Month Year Day Month Year




Nickname (if any)

CONTACT INFORMATION (where you can be contacted by a prospective host family) Telephone___________________________________________________________ Best time to call _____________________ Alternate phone _____________________________________________________ Best time to call ____________________ Mobile phone ________________________________________________________ Best time to call ____________________ E-mail__________________________________________ How often do you check your e-mail _______________________ EMERGENCY CONTACT Name ________________________________ Relationship to you__________________ E-mail_________________________ Home phone_____________________ Work phone_________________________ Mobile phone______________________ Does this person speak English? Yes No If no, what language spoken___________________________________ Other instructions ______________________________________________________________________________________
Au Pair International Au Pair Application 072706

Name:_________________________________________________ Age: _____ Country: ____________________________ CHILDCARE EXPERIENCE Please estimate your total hours of child care experience (required) (including family related child care experience): Hours of experience caring for: Children 0 2 years of age (hours) Children older than 2 years (hours)

Please describe all the ways in which you have gained your child care experience: Nanny Day care center for children Support school teacher Au pair* Caring for younger family members Coaching childrens sports Babysitting, evening Youth or church group/club Teaching after school activities Babysitting, daytime Summer activity camp Music teacher Tutoring children School teacher, full time Other* *Please describe _______________________________________________________________________________________ I have experience in these areas caring for children 0 2 years of age: Preparing baby formula (milk) Putting a baby to bed Feeding a baby with a bottle Burping a baby Feeding a baby with a spoon/fork Preparing baby food Bathing a baby Dealing with tantrums I have experience in these areas caring for children older than 2 years of age: Giving baths and/or putting to bed Involving kids in play and activities Assisting with homework Doing arts and crafts projects Teaching or tutoring Playing indoors Child care experience summary (please all that apply): Experience with: Newborn - 2 year 2 - 6 years 6 + years 2 or more children at the same time Children with mental disabilities* Children with physical disabilities* Children with minor or learning disabilities* * If yes, please describe your experience in caring for children with disabilities _____________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Will you continue working with children until departure? Yes No If yes, please explain? ____________________________________________________________________________________ _______________________________________________________________________________________________________ Describe talents/skills you have that are useful when caring for children ___________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Please list any leader/instructor/tutor role you have had ________________________________________________________ _______________________________________________________________________________________________________ Please describe your experience with household duties _________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________
Au Pair International Au Pair Application 072706

Changing a diaper Caring for a colicky baby Playing with and involving baby in age appropriate activates Playing outdoors Potty training Dealing with tantrums

Willing to care for : Note: Your chances of being placed with a family will greatly improve if you are willing to care for two or more children and if you are willing to care for children younger than two years of age.

Name:___________________________ Age: _____ Country: _______________________________________________ Describe examples of your experience caring for children. Please continue on or write entire description on separate paper. . If your experience is from working in a day care center or school, please list age and number of children. Examples may include experience caring for family members (however, your references must be non-family related). Child care experience #1 Type of child care _____________________ Total hours _________________ Hours per time________________________ Number and ages of children ________________________________________ Reference provided Yes No Describe activities/responsibilities __________________________________________________________________________ ______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ Child care experience #2 Type of child care _____________________ Total hours _________________ Hours per time_________________________ Number and ages of children ________________________________________ Reference provided Yes No Describe activities/responsibilities __________________________________________________________________________ ______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ Child care experience #3 Type of child care _____________________ Total hours _________________ Hours per time________________________ Number and ages of children ________________________________________ Reference provided Yes No Describe activities/responsibilities __________________________________________________________________________ ______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________

DRIVING EXPERIENCE How long have you had a full drivers license (including practical and theory test)? ________ Do you own your own car: Rate your driving skills: Excellent How often do you drive per week: Have you ever had a car accident? Have you ever had a speeding ticket? Yes Good Everyday Yes Yes No Fair 3-5 days Highway No No Yes Yes No No

Dont have one

If yes, for how long?___________________________ Poor 1-2 days City I cant drive Less than once per week Country

What kinds of roads do you usually drive on?

(If yes, please explain on separate paper) I dont know

Do you feel comfortable driving on roads with snow? Are you willing to drive in the US as an au pair?

Au Pair International Au Pair Application 072706

Name:___________________________ Age: _____ Country: _______________________________________________ EDUCATION AND WORK EXPEREINCE What is your current occupation? Student Recent graduate Employed as _____________________________

Please describe the type of education you have beyond secondary school _________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ What grades/scores did you achieve? At secondary school: Top At post-secondary school: Top Good Good Medium Medium Average Average Low Low Not applicable Not applicable

Give a brief summary of jobs you have held, duration and duties (including part time and summer vacation jobs) _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ ______________________________________________________________________________________________________ What are your long term career goals? _______________________________________________________________________ What do you plan to do after the au pair program? _____________________________________________________________ ______________________________________________________________________________________________________

SKILLS, INTERESTES, HOBBIES English proficiency: Excellent Good Fair Poor Years of studying ______________________ Your native language ____________________ Other languages spoken __________________________________________ Do you have formal safety training or certificates (e.g. First Aid, water safety) Describe your swimming skills: Excellent Good Fair

_____________________________________________________________________________________________________ Poor I cant swim

Describe any skills/participation in the following areas (including past and current hobbies and interests): Sports, Outdoor (swimming, soccer, skiing, jogging, hiking, sailing, camping, girl scouts, etc.) _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Arts, Crafts and Creative (cooking, photography, writing, design, handicrafts, gardening, etc.) _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Music (instruments you play, singing, reading music, etc.) _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Other (computers, travel, etc.) _____________________________________________________________________________________________________ _____________________________________________________________________________________________________
Au Pair International Au Pair Application 072706

Name:___________________________ Age: _____ Country: _______________________________________________ FAMILY BACKGROUND Describe where you grew up and pets you have/had (select all that apply): Urban Large city Farm Suburban Small city Dog Town/village Rural area Cat Currently living: With my parents Yes No Farm animals Other pets

I have lived away from home for (time): _______________________________ If yes: Weekly Special occasions Religion ___________________

Do you attend church/temple?

Number of siblings _______ Ages and names of siblings _________________________________________________________ _____________________________________________________________________________________________________

GENERAL What are your favorite things to do in your spare time? __________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ Have you traveled outside your home country for 2 months or more? _______________________________________________ Please describe a typical evening during the week ______________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ Please describe a typical weekend evening ____________________________________________________________________ _______________________________________________________________________________________________________ ______________________________________________________________________________________________________ Why do you want to participate in the au pair program? ________________________________________________________ ____________________________________________________________________________________________________ Have you been convicted of or charged with a criminal offence? Have you been a victim of physical, sexual or emotional abuse? Do you have chronic/recurring health problems (e.g. asthma, diabetes)? Do you take any medication? Have you received treatment for an emotional problem (e.g. anorexia, depression)? Do you have allergies or fears of household pets? Do you have food allergies? Do you follow a special diet? Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No

If yes on any, please give details __________________________________________________________________________ _______________________________________________________________________________________________________ Do you have any condition that could affect your performance as an au pair: Yes No If yes, please specify ___________________________________________________________________________________ Do you smoke? Yes No If yes, cigarettes per day _____ Are you willing to quit smoking? Yes No

If you are a smoker, you must agree to obey the household rules of your host family. These rules might include not smoking in or around the house or when responsible for the children. A failure to follow the rules set regarding smoking may result in your dismissal from the program. Do you agree to follow the host familys rules for smoking? Yes No
Au Pair International Au Pair Application 072706


(If you are a applying for regular au pair, you do not need to fill in this page)

Name:___________________________ Age: _____ Nationality: ________________________________________________ Au Pair Professionnel applicants must have at least 2 years of full time child care experience (as a nanny, child care provider or nursery school teacher) or be a certified child care provider or hold a kindergarten or elementary school teaching degree. Copies of certificates/diplomas and additional references must be provided for the Au Pair Professionnel program. Please bring originals as well as photocopies for verification to your interview. CHILD CARE EDUCATION Describe education and training which qualifies you for the Au Pair Professionnel program, including courses, university and/or other continuing education certificates/degrees. _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ FULL TIME CHILD CARE EXPERIENCE Describe all full time child care positions and responsibilities held and length of employment at each position. Attach reference letter from each employer. _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ What are your future career plans involving children? ___________________________________________________________ _______________________________________________________________________________________________________ How will being an Au Pair Professionnel help you achieve these goals? _______________________________________________________________________________________________________ _______________________________________________________________________________________________________

Au Pair International Au Pair Application 072706

Au Pair International


The following agreement (Agreement) is entered into between Au Pair International, a Colorado Corporation (API) and (first and last name of au pair) ___________________________ (I) and outlines a minimum standard of participation and conduct for the Au Pair Program (Program). I, the undersigned, agree that Program regulations issued by the United States Department of State (22 CFR 62.31) (Regulations) and API information, guidelines, brochures and handbooks are deemed incorporated in this Agreement. I acknowledge receipt of a copy of the Regulations as they apply to me. I understand that if there is any confusion between this Agreement and the terms of any other contracts, agreements, or API materials of any kind, the terms of this Agreement shall prevail. Qualifications and Acceptance: I understand that the Program is a minimum twelve (12) month long J-1 Visa cultural exchange child care program in the USA. I confirm that I comply with all the requirements for the Program including, but not limited to; that I have never been charged with or convicted of a criminal offence; I have not previously participated in an au pair program in the USA; I have successfully completed my secondary school and I am in good health. I confirm that the information I have given in my au pair application is accurate; all qualifications described, certificates and references provided are genuine. I understand that in order to care for children under the age of two I must have at least 200 hours of documented infant child care experience. I understand that API has the exclusive right to determine my suitability for acceptance and for my continued participation in the Program. 3. I understand that it is entirely my choice to participate and continue in the Program and to accept or decline a placement with a host family presented to me, and that it is my responsibility to read and understand all the information provided to me regarding a prospective host family. I agree to interview with the potential host family by telephone and request additional information, if needed, before accepting the placement. 4. I will complete all visa and screening requirements and obtain a passport valid for at least 26 months after my departure to the USA. 5. I agree to complete the au pair training course and review all pre-departure material before my departure to the USA. 6. I understand that in the event of my late cancellation from the Program prior to departure, API reserves the right to charge a cancellation fee and/or I forfeit my deposit.
1. 2.

Travel and Flights: I understand that Program flights will depart from and return to designated airports, that I am responsible for my own transportation to the specified departure airport in my home country and for transportation to a designated US airport in time for my return flight. I understand that I am responsible for costs prior to departure and upon my return. I understand that API will not be responsible for alternate transportation, or airline baggage costs or airport taxes. I understand that if I am required to pay a flight contribution for my flight to the US, a similar flight contribution for my return flight will apply at the end of the Program. I understand that if I change my ticket after it has been issued, I will be responsible for paying a change fee and other airline penalties. I understand that on the completion of my Program, I am expected to depart on the date and time arranged by API. I understand that API cannot book my return flight for a date later than thirty days after the completion of my Program. 8. I agree to keep the forms DS-2019 and I-94 safe at all times and understand that it is costly and timely to replace lost forms. I understand that, should I wish to travel outside the US during my Program, I must submit (and receive) my DS-2019 form to API for a signature prior to leaving. 9. I understand that if I am in good standing with the Program, I may legally remain in the US for 13 month after my arrival date, but that the expiration date on my visa may show an expiration date earlier than the 13 months. For this reason I am recommended to not travel abroad during my 13th month as I might no be able to re-enter the US during this time.

Program Rules and US Regulations: 10. I understand that during my Program participation: i) I may provide child care and light child care related housework for up to 45 hours per week and up to 10 hours per day; ii) I will be compensated at a weekly stipend by my host family in conformance with the requirements of the Fair Labor Standards Act as interpreted and implemented by the US Department of Labor; iii) I will have a minimum of one and a half days off per week in addition to one complete weekend off each month and receive two weeks of paid vacation; iv) I must register and attend classes at an accredited US post-secondary institution for not less than six semester hours of academic credit or its equivalent. I understand that my host family has agreed to facilitate the enrollment and attendance and to pay the cost of such academic course work in an amount up to $500 and that I will be responsible for educational costs exceeding this amount; v) I may not accept any form of paid employment in the US during my stay other than within my duties as an exchange participant with my current host family; vi) My host family must provide me with a suitable private bedroom; vii) A parent or other responsible adult must remain in the home for the first three days following my arrival; viii) I may not have the sole responsibility of a child younger than three (3) months. If my host family has a child younger than three months of age, a parent or other responsible adult must be present. 11. I understand that active and safe care of the children is my first priority as an au pair. I agree to be diligent, conscientious and involved while caring for children and to never leave a child unattended and to never put a child at risk in any way. I agree to limit personal Internet or phone communication while caring for children. I understand that by caring for children I am assuming a great responsibility. 12. I understand that all vacation and free time must be planned and mutually agreed upon in advance with my host family. 13. I agree to perform the child care responsibilities outlined by my host family to the best of my ability and due respect, and make every effort to act as a caring, responsible family member, and will abide by my host familys household rules. I will discuss and agree to the rules for use of Internet, cell phone and phone use with my host family. I will accept any cultural differences in the spirit of cultural exchange. 14. I understand that I will be responsible for all personal debts (personal phone calls, gas usage, etc.) during my Program. 15. I agree to not use an automobile without express permission from the owner and that any agreement to use any automobile is strictly between the automobiles owner and me. I agree to not use an automobile unless I have the required papers for driving in the state and the owner has obtained all mandatory automobile insurance coverage required for me. I understand that I am strongly recommended to obtain a state drivers license even in states that does not specifically require it. I understand that in the event of an automobile accident, I may be liable for an insurance deductible up to USD 500 per accident. I understand that if I do not have a local US state drivers license, I need to have my foreign drivers license and my international drivers permit with me when driving. 16. I understand that during the Program, I will be covered under basic health insurance and that the deductible, as stated on my insurance card, applies per illness/accident. Insurance provided by API is valid from the start date to the end date of the Program. I understand that in order to have insurance coverage during my 13th month, I must purchase such insurance. I agree to and understand the insurance policy and agree to pay for any medical or transportation expenses that are not covered by the insurance. I understand that any conditions or illness I am suffering from prior to entering the US will not be covered under any insurance. I release API from any liability relating to any medical care received. I understand that my insurance and participation in the Program does not cover costs related to court appearance assistance, liability insurance or legal fees.
Au Pair International Au Pair Application 072706

Au Pair International
Supervision, Monitoring and Support: 17. I will co-operate fully with those supervising the Program on my behalf, maintain monthly contact with my local Area Director or other API representative in my Area Directors absence and abide by any reasonable instructions they may give me. In addition to the terms of this Agreement, I agree to abide by additional reasonable terms and conditions stipulated by API during the Program. 18. I agree to, as soon as possible, notify my local Area Director in case of dissatisfaction, concerns and/or problems including, but not limited to; safety, welfare, adjustment to my host family and/or the American culture, misunderstandings, disagreements or problems with my host family, my health, fulfilling my educational requirement, homesickness, language or other. In situations where I am having problems with my host family, I agree to consult with and/or meet with my local Area Director or other API representative(s) and to follow APIs mediation guidelines as outlined in the au pair handbook and by API staff. 19. I agree to contact my API Regional Director if my local Area Director does not provide the supervision and support as required. 20. I will immediately report to API unusual or serious situations or incidents involving either myself or my host family. 21. I understand that an API representative will attempt to contact me within forty-eight hours of my arrival and meet with me and my host parent(s) within two weeks of my arrival. I agree to make myself available for these contacts and to immediately contact my Area Director or Regional Director if these contacts have not taken place. 22. I understand that I am recommended to keep funds of a minimum of USD 500 for emergency purposes during the Program. Rematch During the Program: that API does not guarantee that an au pair will have the opportunity to re-match during the Program and that such decision will be at APIs sole discretion. 24. If problems with my host family cannot be resolved and I am recommended for future placement, I understand that, at APIs discretion, API will use reasonable efforts to find new host family for me. I understand that API may be required to disclose information received from my original host family regarding my stay, performance and behavior while with their family. 25. During a re-match process, I shall, if possible, continue to live with my current host family who, in their discretion, may request me to provide, or not to provide, child care for their children. If I can not remain with my host family, API will make reasonable attempt to find temporary housing for me. I agree to remain in contact with API at all times and to make myself available to be interviewed by potential new host families. 26. I understand that if my placement and/or participation in the program is/are deemed unsatisfactory by API for whatever reason, API will reassess my suitability for future placement. If a recommendation for future placement cannot be provided by my host family, my Area Director and/or my Regional Director, and/or a new family placement cannot be found within a reasonable period or due to my behavior or if I refuse to be placed; my participation in the Program will be terminated and be subject to the standard termination procedures outlined in this Agreement.
23. I understand

Early Termination and Suitability Procedure: 27. I understand that I may be terminated from the Program if I do not successfully complete the 12 month long Program with API for reasons including but not limited to: if I leave my host family without prior consent from API; if I decide to terminate my participation and return to my home country before the end of my 12 month long Program; if I am removed from the Program at the discretion of API in accordance with this Agreement; if I do not fully participate in training, academic courses and monthly meetings/contacts; if I in any way violate this Agreement; or if I put myself in a situation where I cannot be placed with a new host family. Such termination may result in any or all of the following: a. I will forfeit the good faith deposit; b. I will forfeit the return ticket and I will be required to make my own arrangements to return to my home country at my own expense; c. I will no longer receive the support of my host family or API; d. My API insurance coverage will no longer be valid and no part of it refunded; e. API will not provide me with housing. f. My J-1 visa will no longer be valid; and; g. If I remain in the USA after an agreed departure date, my status will be reported to US Immigration. Program Extension: 28. I understand that au pairs may apply to extend their Program participation for additional 6, 9 or 12 months beyond the first 12 Program months. I understand that I may apply to extend my Program participation with my current host family or to be considered for placement with a new host family during the extension period. I understand that in order to extend my Program I must submit the Extension Program Application and formally be approved for the extension. Agreement between Au Pair and Originating Exchange Organization: 29. I understand that API is not a party to any agreement or translations of agreements between me and the Originating Exchange Organization in my home or other country or between me and other organizations including, but not limited to, other US or international agencies, travel agencies and/or insurance companies. API assumes no duties or responsibilities for any acts or omissions of agreements between me and other parties. General Release, Indemnification and Hold Harmless Provisions: As a condition of the my participation in the Program, I agree to release and hold harmless API, its employees, officers, subsidiaries, agents and/or affiliated organizations for injury, loss, delay, and/or any other damage and/or expense incurred by me or any other person due to (i) any incident beyond APIs reasonable control, including without limitation, acts of God, acts of war, or government actions and restrictions, (ii) any events directly or indirectly caused, in whole or in part, by intentional or negligent acts or omissions by any third party, including but not limited to any member, guest, employee or agent of the host family or other persons in the host country, even if APIs negligence is alleged to have contributed to the event; (iii) risks associated with foreign travel and living abroad, including but not limited to, risks associated with health care services, living conditions, sanitation conditions, road and transportation systems, criminal justice systems, civil liberty laws, customs and values; (iv) any differences in the living conditions and standards between my home and home country and the host home and host country; and/or (v) any act or omission of the Originating Exchange Organization. As a further condition of my participation in the Program, I agree to indemnify and hold harmless API, its employees, officers, subsidiaries, agents and/or affiliated organizations from any liability or expense, including court costs and attorney fees, resulting from any injury, loss or any other damage or expense caused by me during my participation in the Program. I agree that API and/or its affiliates, without liability or expense to themselves, may take such actions as it considers necessary regarding my health and safety during my participation in the Program. My signature below indicates acceptance of the terms of this Agreement, and is legally binding. No alteration of the terms of this Agreement will be valid unless approved by Au Pair International in writing. I have retained a copy of this Agreement. This agreement shall be governed by the laws of the State of Colorado, USA. Signature ______________________________________ Date ___/_____/______ Print name _________________________________________

Au Pair International Au Pair Application 072706

Au Pair International
Host Family and Au Pair Agreement

Instructions The US Department of State requires that the au pair and the host family sign a written agreement that outlines the au pairs' obligation to provide child care service. Please sign, date and submit together with your application.

This agreement is for au pair participants only (not EduCare participants) and their host family. As an au pair/host family in a designated US Department of State Au Pair Program, I/we understand and agree to adhere to the following: An au pair is not to provide more than 45 hours of child care services per week, including hours when the au pair is caring for sleeping children. An au pair is not to provide more than 10 hours of child care on any given day, including hours when the au pair is caring for sleeping children. An au pair is to receive a minimum of one and a half days off per week in addition to one weekend (Friday evening to Monday morning) off each month. An au pair is to receive two weeks of paid vacation during his/her stay in the United States (to be mutually agreed upon between the host family and au pair). An au pair is to receive the minimum weekly stipend as stipulated by regulations governing au pair programs, currently $139.05, regardless of number of hours of child care provided. An au pair must register and attend classes at an accredited US post-secondary institution for not less than six semester hours of academic credit or its equivalent. I/We understand that non-participation in this education component is a violation of program guidelines. A host family will reimburse tuition costs, transportation costs and costs of related materials incurred by the au pair in meeting this education requirement, up to a maximum of $500 per year.

I/We have read and understand the information outlined above and agree to adhere to this and other program regulations established by the US Department of State. ____________________________
Print name, US host parent/guardian on behalf of host family/host parents

Signature, US host parent/guardian on behalf of host family/host parents


Print name, au pair

Signature of au pair


Au Pair International Au Pair Application 072706


Au Pair International
Training and Information Notification Form
Please sign and return this form to your local Au Pair International representative after you have been matched with a host family, but before departing for the US. If you are missing any of the items below, do not understand information that has been given to you or if you have not been interviewed by your host family, you must contact your local representative.

Before departing to the USA: I confirm that I have been interviewed by telephone by my host family. I confirm that I have completed the 32 hour video training course; including 24 hours of child development (whereof 4 is devoted to specific training for children under the age of two) and 8 hours of child safety instruction (whereof 4 hours is infant-related); thus, meeting the training requirements required by Au Pair International and the US Department of State. I confirm that I have received information from Au Pair International, including the following documents: o o o o The Au Pair Handbook including the Department of States regulations, welcome letter and welcome brochure regarding the au pair program. Copy of my host familys application. A profile of local educational opportunities and institutions in the USA. A detailed summary of travel arrangements.

I understand by signing this statement that I am responsible for the information provided to me and hold Au Pair International harmless of any negligence.

________________________________________________________ ______________________________ Print name, au pair Country _______________________________________________________ Signature, au pair ______________________________ Date

Au Pair International Au Pair Application 072706