Please complete all sections
Surname:
Forenames:	Father: Mother:
Home Address:
Home Telephone No:
Business Telephone No:	Father: Mother:
Mobile Phone No:	Father: Mother:
Emergency Telephone No:	eg relative, neighbour , close friend etc
email:	Home: Business:
Children's Names and Dates of Birth:
Childrens times at School/Nursery:
Family Information
Nationality:
Main language spoken at home:
Note: Au Pairs are only allowed (by law) to go to family where English is spoken at Home. – If a girl/boy is placed with a family, and subsequently we are informed that English is not being spoken at home – the girl/boy will be removed and no refund will be applicable – see Terms
No of Adults in household:
Father's Occupation:	Full Time Part Time
Mothers Occupation:	Full Time Part Time
If either Parent does shift work please give details:
Hours away from home:	Father: Mother:
Religion:	Observant Yes No
Do you have any Pets?	Yes No - If yes, give details
Will the Au Pair have to look after them?	Yes No
Nearest Language School:	Distance from home: miles
Nearest Bus Stop/Bus Station:	Distance from home: miles
Will the au pair have to accompany the children to school?	Yes No -- If yes, choose method: walk public transport family car
Is your home in the:	Village Countryside Suburb Town City
Nearest	Station: Airport:
Do you need a driver?	Yes No
if yes, give details of vehicles:
Please note it is your responsibility to make sure there is adequate insurance/up to date MOT etc
Nearest large town:
How far from?	Home: miles ----- Shops: miles
If the Au Pair can cycle, will you be able to provide a bicycle?	Yes No
Do you require a Non Smoker?	Essential Smoke Outside Don't Mind
Do any members of your family smoke:	Yes No
Will you be offering any extras?	Bus Pass Gym Membership Courses Other
if Other, please give details:
FAMILY INFORMATION
Family Home type:	House Flat Apartment
No of Rooms:	Living: Bedrooms: Bathrooms:
Details of other Rooms:
Au Pair has own:	Bedroom Yes No -- Bathroom Yes No
	TV Yes No -- Hi-Fi Yes No -- Car Yes No
Would you consider a Male Au Pair?	Yes No
DUTIES & RESPONSIBILITIES OF AU PAIR:
Do you have any other domestic help?	Yes No
if yes give details:
Have you had an Au Pair before?	Yes No
if yes, give details:
How much pocket money will you pay your Au Pair?	£ (See Guidelines)
How many hours a week will your Au Pair work:	(See Guidelines)
Please give details of free time:
Do you require an :	Au Pair Au Pair +
Commencement Date :	Length of stay:
Where did you hear about our Agency?	Web Site Search Engine Directory Recommendation If Search Engine which one Google MSN Yahoo Other
Do you have any objections to the Agency passing your telephone number to another Au Pair in your area, thereby allowing new Au Pairs to the area to have friends? Tick if ok
It is VERY IMPORTANT that the Agency is informed of any details that will assist them in finding the correct Au Pair for the family. (Please include any dietary needs, medical condition, origins of the family, etc.)
Please give details here:
I confirm that I have read and agree to the Terms & Conditions of Business of The Agency I understand Au Pairs are not qualified in Childcare, and therefore they should not be given sole charge of children under the age of 2. I understand that The Agency cannot be held responsible for any loss, damage or injury caused to persons or property by my Au Pair.
To Agree:	Tick here and enter date:

---

IF YOU ARE NOT SURE OF AN ANSWER THAT IS REQUIRED, PLEASE ENTER 'Don't know'


The Agency require Single Parent Fathers to provide 2 references. Please send them either by post or email.